State and Local Agency WIC Clinic Staff - SLT

WIC Nutrition Assessment and Tailoring Study In-Person Site Visit Data Collection

C2a_Identified Risks Data Collection Form

State and Local Agency WIC Clinic Staff - SLT

OMB: 0584-0663

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Appendix C2a. Identified Risks Data Collection Form


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OMB Control No: 0584-0663

Expiration Date: xx/xx/20xx



Expiration Date: 03/31/2019




WIC Nutrition Assessment and Tailoring Study

Observation of Nutrition Services Components of WIC Certification



Clinic Site ID: _______ Participant ID: _______ Staff ID: ______

Observer Initials:

Date: ____________________

(Month, Day, Year)

Note to Observer: After the participant leaves her/their assessment, ask the WIC CPA the following questions, using the nutrition risk checklist provided on the following pages.


Questions to ask the WIC CPA who conducted the assessment after the observation

  1. For research purposes, can you tell us whether the participants you just served were new to the WIC program or have participated before in a prior pregnancy or for another infant or child?

This is this participant’s first WIC enrollment

This participant has previously been enrolled in WIC or has had an infant or child enrolled in WIC before.

  1. (If the visit included at least one child certification) Can you tell us the date of birth of the child (or children) who you conducted the nutrition assessment for at this visit?

Child One ____ / _____ / ______

Child Two ____ / _____ / ______

Child Three ____ / _____ / ______





This information is being collected to assist the Food and Nutrition Service in obtaining a comprehensive and detailed description of the WIC nutrition risk assessment process and the ways in which participant benefits are tailored to address the assessment results. This is a voluntary collection and FNS will use the information to improve the delivery and tailoring of WIC services and increase satisfaction of both staff and participants. This collection does request personally identifiable information under the Privacy Act of 1974. 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 0584-0663. The time required to complete this information collection is estimated to average 5 minutes (0.08 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN:  PRA (0584-0663). Do not return the completed form to this address.

  1. Did you make any modifications to the standard food package prescription for this/these participant/s, based on the information you learned during the nutrition assessment?

Yes No

If yes, what modifications did you make?

  1. Can you please tell me the names of all the nutrition risks you identified for this/these participant/s today? (Mark all that apply on the Nutrition Risks Checklist below.)

  2. Was this/Were any of the participant/s determined to be “high risk”? Yes No

[If yes] Which of these risks made the participant “high risk”? (Mark all that apply on the Nutrition Risks Checklist below.)

  1. Of all the nutrition risks identified for this participant, which ones:

A) Were automatically generated by the Management Information System?

B) Did you enter manually into the MIS?

C) Are not included in the MIS record for this participant (for whatever reason)?

(On the Nutrition Risks Checklist below, mark A, B, or C for each risk identified)

  1. Was it addressed by a referral to an internal WIC staff member or to an external health or social service program or organization? (On the Nutrition Risks Checklist below, enter I (internal) and/or E (external) or N (neither) for each risk identified.)

  2. Was it addressed in nutrition education and counseling? (On the Nutrition Risks Checklist below, enter yes or no for each risk identified.)

Nutrition Risks Checklist

Risk Code

Risk Criteria Title

Nutrition Risks Identified During Assessment

(Question 4)

Identified Risk = High Risk?

(Question 5)

Automatically generated (A), Manually entered (B), or Not Included in MIS (C) (Question 6)

Risk Addressed by Internal (I) or External (E) Referral, or Neither (N) (Question 7)

Risk Addressed by Education (Yes or No) (Question 8)

Anthropometric



101

Underweight (Women)






103

Underweight or At Risk of Becoming Underweight (Infants and Children)






111

Overweight (Women)






113

Obese (Children 2 to 5 years of Age)






114

Overweight or At Risk of Overweight (Infants and Children)






115

High Weight for Length (Infants and Children < 24 mths of Age)






121

Short Stature or At Risk of Short Stature (Infants and Children)






131

Low Maternal Weight Gain






132

Maternal Weight Loss During Pregnancy






133

High Maternal Weight Gain






134

Failure to Thrive






135

Slowed / Faltering Growth Pattern






141

Low Birth Weight and Very Low Birth Weight






142

Preterm or Early Term Delivery






151

Small for Gestational Age






152

Low Head Circumference






153

Large for Gestational Age






Specify Anthropometric risk criteria not on list:

















Biochemical



201

Low Hematocrit / Low Hemoglobin






211

Elevated Blood Lead Levels






Specify Biochemical risk criteria not on list:




















Clinical/Health/Medical






301

Hyperemesis Gravidarum






302

Gestational Diabetes






303

History of Gestational Diabetes






304

History of Preeclampsia






311

History of Preterm or Early Term Delivery






312

History of Low Birth Weight






321

History of Spontaneous Abortion, Fetal or Neonatal Loss






331

Pregnancy at a Young Age






332

Closely Spaced Pregnancies






333

High Parity and Young Age






334

Lack of or Inadequate Prenatal Care






335

Multi-fetal Gestation






336

Fetal Growth Restriction






337

History of Birth of a Large for Gestational Age Infant






338

Pregnant Woman Currently Breastfeeding






339

History of Birth with Nutrition Related Congenital or Birth Defect






341

Nutrient Deficiency Diseases






342

Gastrointestinal Disorders






343

Diabetes Mellitus






344

Thyroid Disorders






345

Hypertension and Prehypertension






346

Renal Disease






347

Cancer






348

Central Nervous System Disorders






349

Genetic and Congenital disorders






351

Inborn Errors of Metabolism






352a

Infectious Diseases—Acute






352b

Infectious Diseases—Chronic






353

Food Allergies






354

Celiac Disease






355

Lactose Intolerance






356

Hypoglycemia






357

Drug Nutrient Interactions






358

Eating Disorders






359

Recent Major Surgery, Trauma, Burns






360

Other Medical Conditions






361

Depression






362

Developmental, Sensory or Motor Disabilities Interfering with the Ability to Eat






363

Pre-Diabetes






371

Maternal Smoking






372

Alcohol and Illegal Drug Use






381

Oral Health Conditions






382

Fetal Alcohol Syndrome






383

Neonatal Abstinence Syndrome






Specify Clinical/Health/Medical risk criteria not on list:

















Dietary



401

Failure to Meet Dietary Guidelines for Americans






411

Inappropriate Nutrition Practices for Infants






425

Inappropriate Nutrition Practices for Children






427

Inappropriate Nutrition Practices for Woman






428

Dietary Risk Associated with Complementary Feeding Practices






Specify Dietary risk criteria not on list:

















Other Risks



501

Possibility of Regression






502

Transfer of Certification






503

Presumptive Eligibility for Pregnant Woman






601

Breastfeeding Mother of Infant at Nutritional Risk






602

Breastfeeding Complications or Potential Complications (Women)






603

Breastfeeding Complications or Potential Complications (Infants)






701

Infant Up to 6 Months Old of WIC Mother or of a Woman Who Would Have Been Eligible During Pregnancy






702

Breastfeeding Infant of Woman at Nutritional Risk






703

Infant Born of Woman with Mental Retardation or Alcohol or Drug Abuse During Most Recent Pregnancy






801

Homelessness






802

Migrancy






901

Recipient of Abuse






902

Woman or Infant/Child of Primary Caregiver with Limited Ability to Make Feeding Decisions and/or Prepare Food






903

Foster Care






904

Environmental Tobacco Smoke Exposure






Specify Other Risks risk criteria not on list:












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