Appendix C5 Clinic Observation Form

C5_Clinic Observation Form.docx

WIC Nutrition Assessment and Tailoring Study

Appendix C5 Clinic Observation Form

OMB: 0584-0663

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Appendix C5. Clinic Observation Form

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OMB Control No: 0584-XXX

Expiration Date: XX/XX/XXXX



Expiration Date: 03/31/2019



WIC Nutrition Assessment and Tailoring Study

Clinic Observation Form

______________________________________________________________________________

Clinic Site ID: _______ Observer Initials: _______

Date: ____________________

(Month, Day, Year)

_____________________________________________________________________________

GENERAL SITE FACILITIES (from Observation)


1. Number of waiting rooms/areas: ___________


2. Is the waiting room solely for WIC or shared with other programs?

  • Only for WIC – GO TO Q4

  • Shared


3. What other programs share the space?

  • Only for pregnant women, mothers and/or children

  • Broader adult population

  • Other, specify: ______________________


4. Private area for certification intake process (income, address): Yes No


5. Private area for anthropometric measurements: Yes No


6. Private area for hematological measurements: Yes No


7. Private area for certification sessions: Yes No


8. Private area for individual education sessions: Yes No


9. Signage encourages breastfeeding anywhere in the facility, including the waiting room:

Yes No


10. Private area available for breastfeeding mothers (not including the bathroom):

Yes No


11. Separate room for group education: Yes No


12. Educational materials related to nutrition and health, such as posters or pamphlets, available in waiting room: Yes No


13. Referral resources available in waiting room: Yes No


14. Toys/books/activities available to entertain children while in the waiting room: Yes No


15. Educational videos related to nutrition and health shown in waiting room: Yes No


16. Signage available directing participants to check-in desk: Yes No Not Needed



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