Caregivers of Former WIC Children (Individuals/Households)

OMB Approval No. 0584-0580

Approval Expires: XX/XX/20XX

APPENDIX H1

72-month text or email provider measures - English

As we discussed on the phone, please send a copy of the doctor office printout of your child’s height and weight from the last doctor visit. You can send it via mail to:

Bryan Williams

Westat

1600 Research Blvd.

Rockville, MD 20850

OR you can take a picture of the printout and email at [SL EMAIL ADDRESS] or text it to me at [SL STUDY CELL NUMBER]. Please be sure to cover your child’s name with a slip of paper before taking the picture to protect your privacy.

We will put $70 on your prepaid MasterCard when we receive the measurements.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0580.  The time required to complete this information collection is estimated to average 3 minutes (0.05 hours) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0580).  Do not return the completed form to this address.