Appendix C5 Clinic Observation Form

Appendix C5. Clinic Observation Form

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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