WIC Local Agency Directors and WIC Clinic Staff - Profit/Non-Profit Businesses

WIC Nutrition Assessment and Tailoring Study

C4_Clinic Site Information Form.xlsx

WIC Local Agency Directors and WIC Clinic Staff - Profit/Non-Profit Businesses

OMB: 0584-0663

Document [xlsx]
Download: xlsx | pdf

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
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy