Caregivers of Former WIC Children (Individuals/Households)

Appendix D5

CONTACT INFORMATION FORM - ENGLISH

	OMB Approval No. 0584-0580 Approval Expires: XX/XX/20XX Keep in touch with Feeding My Baby!
PLEASE HELP US STAY IN TOUCH BY UPDATING YOUR CONTACT INFORMATION BELOW AND MAILING IT BACK TO US IN THE ENCLOSED ENVELOPE. PLEASE COMPLETE EVEN IF YOUR INFORMATION HAS NOT CHANGED

YOU WILL RECEIVE $5 FOR RETURNING THE COMPLETED FORM.

____________________________________________________

YOUR NAME

____________________________________________________

STREET ADDRESS Apt. #

____________________________________________________

CITY STATE ZIPCODE

____________________________________________________

PHONE

____________________________________________________

CELL PHONE CELL PHONE COMPANY (VERIZON, ATT, ETC.)

____________________________________________________

CAN WE TEXT YOU?  YES  NO

____________________________________________________

EMAIL

PLEASE TELL US THE NAME AND CONTACT INFORMATION OF 2 PEOPLE WHO ALWAYS KNOW HOW TO FIND YOU, PREFERABLY FAMILY:

#1. ____________________________________________________

NAME RELATIONSHIP (e.g., Mother, Friend)

____________________________________________________

STREET ADDRESS Apt. #

____________________________________________________

CITY STATE ZIPCODE

____________________________________________________

PHONE

____________________________________________________

CELL PHONE

____________________________________________________

EMAIL

#2. ____________________________________________________

NAME RELATIONSHIP (e.g., Mother, Friend)

____________________________________________________

STREET ADDRESS Apt. #

____________________________________________________

CITY STATE ZIPCODE

____________________________________________________

PHONE

____________________________________________________

CELL PHONE

____________________________________________________

EMAIL

Privacy Act Statement

Authority: Per §246.26 (i)(C), USDA Food and Nutrition Service is authorized to collect information to enhance the health, education, or well-being of those who use WIC services. Code of Federal Regulations §215.11 requires WIC State and local agency directors to cooperate in the conduct of studies and evaluations. Per §246.2 of the WIC regulations, “local agencies” include public or private non-profit health or human service agencies, Indian Health Service units, and health clinics of ITOs and intertribal councils or groups.

Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration and evaluation of Special Supplemental Program for Women, Infants and Children.

Routine Use: FNS published a system of record notice (SORN) titled FNS-8 USDA/FNS Studies and Reports in the Federal Register on April 25, 1991, volume 56, pages 19078-19080, that discusses the terms of protections that will be provided to respondents.

Disclosure: Your participation in the collection of contact information is voluntary.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB 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 6 minutes (0.10 hours), 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, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314, ATTN: PRA (0584-0580).  Do not return the completed form to this address.