State and Local Agency WIC Clinic Staff - SLT

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Appendix C2a. Identified Risks Data Collection Form





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, 5th 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.)
    6. 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: