WIC Participants - Individuals and Households

Appendix D6. WIC Participant Screener

OMB Control No: 0584-0663 Expiration Date: xx/xx/20xx Expiration Date: 03/31/2019

WIC Nutrition Assessment and Tailoring Study

WIC Participant - Recruitment Screener

We are conducting a very important study for the U.S Department of Agriculture’s Food and Nutrition Service, collecting information to learn more about how WIC services can better meet participants’ nutrition needs. We’d like you to be part of it!  If you agree to help us, you’ll receive a $20 gift card today if you have time to stay for a brief interview after your appointment or in the mail if you do the interview later by phone.  If you’re interested, I only need to ask you one question to find out if you’re eligible for the study. I can then tell you more about the study and you can then decide whether you want to participate or not. Are you interested?

[If yes ask] Are you at least 18 years old?

[If no, not 18] Sorry, you must be at least 18 years old to participate. But thank you for being interested.

[If the answer is yes] Great! Let me tell you about the study and you can decide whether you want to participate.

[If the participant does not want to be part of the study] Okay. Thanks for taking the time to talk to me.

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.