State and Local Agency WIC Clinic Staff - SLT

Appendix C2a. Identified Risks Data Collection Form

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.

2. (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, 5^th Floor, Alexandria, VA 22314 ATTN:  PRA (0584-0663). Do not return the completed form to this address.

3. 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?

4. 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.)

5. 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)

7. 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.)

8. 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: