C2_Nutrition Services Observation Form

Appendix C2. Nutrition Services Observation 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)

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