State and Local Agency WIC Directors and WIC Clinic Staff - SLT

---

Overview

Instructions
Clinic Site Information

---

Sheet 1: Instructions

INSTRUCTIONS
Use this form to record information about each of your WIC clinics.
The information needed includes:
	Clinic name
	ZIP code for clinic location
	Average monthly caseload
	Most common language (other than English) spoken at home by the clinic’s WIC participants
	Percentage of participants who speak the language identified as most common (your best guess is fine)
	Percentage of participants at each clinic with a high risk code
	Percentage of participants at each clinic with only one documented risk
	Number of days per week the clinic is open
	Weekdays when new enrollment and certification appointments are scheduled
If you have this information available in some other format, you may choose to submit those documents to us instead of completing the Excel file. Once you complete the form with the information (or gather your own documents with this information), you may return it to us, or simply plan to provide the information during a phone call.
You may submit the Excel file with clinic information (or your own documents providing this information) and program documents using any of the methods below:
	Upload to site	[FTP address]
	Email	[email protected]
	Fax	1-301-294-2092
	Regular mail	[study mail address]
If you have any questions about this form or the study, please contact the Westat study team at:
	Email	[email protected]
	Telephone	1-855-598-2492

---

Sheet 2: Clinic Site Information

PLEASE ENTER THE FOLLOWING INFORMATION ABOUT EACH CLINIC SITE IN YOUR LOCAL AGENCY.
Clinic name	ZIP code for clinic location	Average monthly caseload	Most common language (other than English) spoken at home by the clinic’s WIC participants	Percent of participants who speak the language identified as most common (from previous column)	Percentage of participants at this clinic with a high risk code	Percentage of participants at this clinic with only one documented risk	Number of days per week the clinic is open	Weekdays when new certification appointments are scheduled