WIC Participants - Individuals and Households

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

C2_Nutrition Services Observation Form

WIC Participants - Individuals and Households

OMB: 0584-0663

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Appendix C2. Nutrition Services Observation 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)

Type of Observation: Appointment was observed in the clinic

Appointment was observed remotely by video call

Appointment was observed remotely by phone



Information to be collected prior to the observation from WIC staff :

WIC Participant Category(ies): (Mark all that apply)

Pregnant

Postpartum woman

Breastfeeding:

Fully Partially No

Infant

Child

Number of people being certified at this visit

______________(#)

Type of Visit (person 1):

Initial WIC enrollment

WIC Recertification

Type of Visit (person 2):

Initial WIC enrollment

WIC Recertification

Type of Visit (person 3+):

(multiple births)

Initial WIC enrollment

WIC Recertification

(Note: Sample filled out for illustration.)

Components of NRA Certification

Visit

WIC Staff Type 1Conducting Session

Activities Conducted






Start Time

End Time

Date

Anthropo-metric

Measure-ments

Laboratory measure-ments

Nutrition assessment discussion

Nutrition education/

counseling

Food package prescription

Referrals

First Session

Nutritionist






10:05_

10:25__


Waiting Time Between Sessions








10:25

10:40


(if applicable) Second session

R.D.





10:40


11:20


(if applicable)

Third Session

NA








__:__


__:__


(if applicable)

Fourth Session

NA








__:__


__:__


Mode of delivery:

  • In-person

  • Video call

  • Telephone

  • Unknown

  • Not conducted

  • Other, specify:

In-person

Other:


Provided by participant’s healthcare provider

Video call

Video call

Video call

Video call





_____________________________________________________________________

Introductory Text at the Start of the Observation

Hello [NAME OF CAREGIVER]. I want to thank you for allowing me to [sit in and] observe your [visit]/[appointment] with the WIC staff today. As we discussed earlier, my colleagues and I are [here at the WIC clinic]/[observing WIC appointments] this week for the WIC Nutrition Assessment and Tailoring Study. We will be observing several visits at this clinic and at many others across the country. We are observing WIC certification appointments to get a better understanding of the different ways WIC clinics conduct them.

During your [visit]/[appointment] today, I will be silent and listen [and watch]. I’ll be taking notes, but my notes will all be about how the certification process is conducted. My notes will not identify you or record the private information you discuss. Please know that if at any point you feel uncomfortable with me observing or taking notes, you should stop the conversation, let me know, and I will leave [the room]/[this call].

Language

Language Spoken by Participant/Caregiver

English Spanish Other _________

If language spoken is not English:

Use of interpreter services?

Yes No, not needed No, needed

(If yes) Type of interpreter services:

Bilingual WIC staff conducted session

Interpreter present

Language line service

Observation of the Workspace/Environment Where the Assessment is Conducted [IF IN-PERSON]

Does the place where the assessment is being conducted provide privacy?

Yes No

Are there toys, books, coloring materials or other activities available for children?

Yes No


Observation of the WIC Certification Visit

At the Beginning of the Nutrition Risk Assessment Session

At the beginning of the session does the WIC CPA2:


Greet the participant warmly

Yes No

Introduce self

Yes No

Make initial positive comments

Yes No

Provide an overview of what will happen during the appointment and about how much time it will take

Yes No

(For new participants)

Did the WIC CPA explain the purpose of the WIC program?


Yes No

Did the WIC CPA provide an explanation of the WIC risk assessment process and its purpose?

Yes No

Gathering Information for the Nutrition Risk Assessment

Were the participant’s height or length and weight measurements available to the CPA during this visit?


Yes, measurements were obtained on day of visit

Yes, recent measurements were obtained from an off-site health care provider

Yes, the participant self-reported measurements taken at home

Current measurements were not available, but the CPA used measurements from the previous visit

No measurements were available to the CPA at the time of the certification visit

Could not be determined

Other, specify:



Were the results of a hemoglobin or hematocrit test available to the CPA during this visit?

Yes, hemoglobin or hematocrit test performed and value assessed on day of visit

Yes, hemoglobin or hematocrit test results were obtained from an off-site health care provider

Current measurements were not available, but the CPA used measurements from the previous visit

No measurements were available to the CPA at the time of the certification visit

Could not be determined

Other, specify:



During the visit, did the WIC CPA refer to any medical information provided directly from a health care provider?


Yes No


If yes, what kind of information was referred to? (Mark all that apply.)


Height/length and weight

Recent Hct/Hgb count

Medical History or other Clinical Information

Dietary/Nutrition Information

Family and Social Environment Information

Other, specify



Did the WIC CPA ask nutrition and health questions of the participant using a questionnaire (paper or on the computer) as her/his guide? (Questions may not be read verbatim or in the order printed on the questionnaire)


Yes No


Observer comment on how tool was used:

How often did the WIC CPA ask follow-up probing questions to clarify and get more details when reviewing or asking questions from an assessment questionnaire?

Always

Frequently

Sometimes

Never asked probing questions


Did the WIC CPA use any other visual aids during the assessment (e.g. food models showing serving size, pictures, other)?

Yes No


If yes, What kind of tools were used?

(Mark all that apply)

Food models

Portion size pictures

Growth charts

Pamphlets/printed material


Other, specify



Which of the following topic areas did the WIC CPA ask about during the assessment component of the session?


  • Health/medical information


  • Feeding/Dietary practices and preferences


  • Breastfeeding intention or practices



  • Immunizations



  • Substance use


  • Family and home environment


  • Other (specify)




Yes No


Yes No


Yes No

Not applicable


Yes No


Yes No


Yes No


Yes No

____________________


During the assessment conversation, did the WIC CPA explore the participant’s cultural behaviors and beliefs?


If yes, please provide examples of the questions the WIC CPA asked to explore the participant’s cultural behaviors and beliefs

o Yes No



Examples:

_____________________________________________

_______________________

Nutrition Risk Assessment Process

(For recertification visits only)

During the assessment, did the WIC CPA refer back to previous visits to ask the participant or caregiver about progress made?

Yes No



Did the WIC CPA explain the participant’s growth/weight gain pattern to participant caregiver?


Yes No

Not applicable, no measurements available


Did the WIC CPA explain the meaning of the Hct/Hgb results to the participant or caregiver?

Yes No

Not applicable, no blood work available


Did the WIC CPA utilize any electronic tools (other than the use of a nutrition or health questionnaire) to help her/him determine the participant’s nutrition risks? (If yes, please ensure these were collected from the Site Director.)


Yes No

As part of the assessment, did the WIC CPA ask the participant or caregiver about her/his nutrition needs and interests?


If yes, did the WIC CPA acknowledge and affirm the participant’s thoughts and concerns?

Yes No




Yes No


What nutrition risks were directly discussed with the participant or caregiver?






If any nutrition risks were directly discussed with the participant or caregiver, was this done in a way that focused primarily on positive changes and/or desirable health outcomes or on deficiencies?


None discussed


Risks discussed (specify): ____________­­­________

_______________________

_______________________


Focused on positive changes and/or desirable health outcomes

Focused on deficiencies


Describe examples of how risks were communicated to justify response choice ______________________________________________


Did the WIC CPA complete the nutrition assessment before providing education/counseling?

Yes No



Breastfeeding Component of Nutrition Assessment

For Pregnant Women and Postpartum Breastfeeding Women

Did the WIC CPA explore the woman’s knowledge about breastfeeding?

Yes No


Did the WIC CPA explore the woman’s thoughts and concerns regarding breastfeeding?

Yes No


Did the WIC CPA ask the woman about her plans for breastfeeding (i.e., for a pregnant woman - whether she plans to breastfeed; for a breastfeeding woman - duration of plans for breastfeeding)

Yes No


Did the WIC CPA assess the introduction of complementary foods as part of her breastfeeding assessment?

Yes No

If yes, who initiated the conversation about the introduction of complementary foods?


WIC staff

Caregiver


Nutrition Education/Counseling (for low and high risk participants)

Following the assessment of risk, was nutrition education/counseling provided to the participant/caregiver by the WIC CPA who conducted the assessment?


If no, how was the nutrition education/counseling provided?









Yes

No



Provided in a one-on-one session by a different WIC staff person

Provided during this visit in a group session

Provided via on-site technology (e.g. computer, kiosk, tablet) Specify method_____________

To be provided via off-site technology (e.g. web-based) at another time Specify ______________

During nutrition education, did the WIC staff specifically address any of the participant or caregiver’s nutrition risks?

Yes

No


To what extent did the nutrition education/counseling component of the visit specifically address the concerns expressed by the participant or caregiver during the assessment conversation?


All participant concerns addressed during nutrition education/counseling

Some, but not all of the concerns expressed by the participant were addressed during nutrition education/counseling

Participant’s concerns were not addressed during nutrition education/counseling



Observer comment to explain response choice:

______________________


If there were many nutrition risks discussed and needs expressed by the participant or caregiver, how was the priority for topics for nutrition education/counseling determined?

Discussion with participant to determine her/his priorities

WIC staff identified the priorities using her/his judgment

No apparent prioritization of topics

Other, specify _________

What nutrition and health topics were discussed during the nutrition education/counseling portion of the visit?)

(Mark all that apply)


Breastfeeding

Calcium Intake

Child feeding practices

Fruits and vegetables

Having enough to eat

Healthy meals

Healthy snacking

Healthy weight for child

Healthy weight for mother

Infant feeding practices

Introduction of solid foods

Iron/anemia

Medical issues (e.g. blood pressure, gestational diabetes)

Milk choices/consumption

Physical activity

Picky eaters

Prenatal nutrition/diet

Protein intake

Shopping for and preparing healthy foods

Sugar-sweetened beverages

Vitamins and mineral supplements

Water consumption

Weaning from the bottle

Whole grains

Other ________________


Did the CPA help the participant set a personal behavior change goal or goals during this visit, based on input from the participant?


If yes, did the educator help the participant or caregiver identify any challenges that might be faced in trying to reach the goal(s)?


Did the education discuss how the participant or caregiver might handle the challenges?



Yes No



Yes No



Yes No


Internal Referrals

During the visit, were any referrals made to internal resources offered by the WIC clinic other than general nutrition education?

Yes

No



If yes, to what types of internal resources was the participant or caregiver referred to for help that day or follow-up after the visit?

(Mark all that apply)

Peer counselor

WIC designated breastfeeding expert (DBE)

WIC registered dietitian

Other (specify):

_______________________


Referrals to External Health and Social Services

During the visit, were any referrals made to specific external health or social service programs or organizations?

Yes

No



If yes, to what types of other health and social service programs or organizations was the participant or caregiver referred to for help?

(Mark all that apply)

Breastfeeding support

Immunizations

Other Health services

Income support (TANF, SSI, UI)

SNAP/Food stamps

Medicaid/CHIP (we will determine what these programs are called in each state)

Substance use counseling

Domestic violence

Housing/Shelter

Child abuse prevention

Emergency food provider

Head Start

Other (Specify) ____________________

____________________

____________________


If any external referrals were made, how was the referral made?

(Mark all that apply)

Referral was provided orally to the participant

o Written information (e.g. brochure)was provided to the participant

WIC staff called the referral organization on behalf of the participant

WIC staff emailed the referral organization

WIC staff texted the referral information to the participant

Other (Specify)

____________________

____________________

Participant Centered Communication Skills

If the caregiver and/or participant sees more than one WIC staff person for the certification visit (starting with the nutrition risk assessment portion of the visit), complete this table of observation questions for the first WIC staff person seen during this visit.

[IF IN-PERSON] Throughout the session, how often did the WIC CPA look directly at the participant (not at the computer)?


[IF REMOTE VIA VIDEO] Throughout the video call, how often did the WIC CPA look directly at the participant (i.e., without breaking eye contact to multitask or look at other screens)?


[IF REMOTE VIA TELEPHONE, SKIP]

For the majority of the time

For some but not the majority of the time

Infrequently

Throughout the session, how often did the WIC CPA use open-ended questions?


Frequently

A few times

Never

Throughout the session when discussing current behaviors, progress and identified nutrition risks, to what extent did the WIC CPA affirm what the participant/caregiver was doing well, emphasizing strengths and positive behaviors rather than focus on her/his weaknesses, deficiencies or negative behaviors?

Always emphasized positive

More often emphasized positive than negative, but not always

More often emphasized negative than positive



Throughout the session, how often did the WIC CPA try to elicit the participant/caregiver’s views and input?


Very Often

Occasionally

Never


[IF IN-PERSON] Did the WIC CPA invite the participant to look at the computer screen for any purpose during the assessment?




Yes

No



Comment: _______________________

_______________________ _______________________

Throughout the session, in what other ways, if any, did the WIC staff appear attentive to the WIC participant or caregiver’s needs or concerns?

Comment: _____________________________________________________________________


Throughout the session, in what ways, if any, did the WIC staff appear not attentive to the WIC participant or caregiver’s needs or concerns?

Comment: ____________________________________________________________________________________________



Closing Text at the End of the Observation:

Thank you for letting me listen and observe. I have learned a lot from this experience.

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.

GO TO APPENDIX C2a. IDENTIFIED RISKS DATA COLLECTION FORM

1 Staff Type Options: Registered dietitian/registered dietitian nutritionist (RD/RDN), Nutritionist (4 year degree/non-RD/RDN), Nurse (Registered Nurse (RN) or Licensed Practical Nurse (LPN)), Paraprofessional, Nutrition assistant/nutrition aide, Breastfeeding peer counselor, Designated breastfeeding experts (including Certified Lactation Counselors, Certified Lactation Educators, and International Board Certified Lactation Consultants), and Clerk/support staff


2 For purposes of this Observation Form, we use the term WIC CPA to refer to the WIC staff member who is conducting the nutrition assessment. Please note that other staff members may conduct all or part of the assessment, and the staff members’ type (e.g., RD/RDN, CPA, etc.) should be indicated in the first table on page 1 of this form.

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 1 minute (0.02 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.


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