Caregivers of Former WIC Children (Individuals/Households)

Appendix C1 - CONTACT INFORMATION FORM - ENGLISH

	OMB Approval No. 0584-0580 Approval Expires: XX/XX/20XX Keep in touch with Feeding My Baby!
PLEASE HELP US STAY IN TOUCH BY UPDATING YOUR CONTACT INFORMATION BELOW AND MAILING IT BACK TO US IN THE ENCLOSED ENVELOPE. PLEASE COMPLETE EVEN IF YOUR INFORMATION HAS NOT CHANGED

YOU WILL RECEIVE A $10 CHECK FOR RETURNING THE COMPLETED FORM.

____________________________________________________

YOUR NAME

____________________________________________________

STREET ADDRESS Apt. #

____________________________________________________

CITY STATE ZIPCODE

____________________________________________________

PHONE

____________________________________________________

CELL PHONE CELL PHONE COMPANY (VERIZON, ATT, ETC.)

____________________________________________________

CAN WE TEXT YOU?  YES  NO

____________________________________________________

EMAIL

PLEASE TELL US THE NAME AND CONTACT INFORMATION OF 2 PEOPLE WHO ALWAYS KNOW HOW TO FIND YOU, PREFERABLY FAMILY:

#1. ____________________________________________________

NAME RELATIONSHIP (e.g., Mother, Friend)

____________________________________________________

STREET ADDRESS Apt. #

____________________________________________________

CITY STATE ZIPCODE

____________________________________________________

PHONE

____________________________________________________

CELL PHONE

____________________________________________________

EMAIL

#2. ____________________________________________________

NAME RELATIONSHIP (e.g., Mother, Friend)

____________________________________________________

STREET ADDRESS Apt. #

____________________________________________________

CITY STATE ZIPCODE

____________________________________________________

PHONE

____________________________________________________

CELL PHONE

____________________________________________________

EMAIL

The Food and Nutrition Service (FNS) is collecting this information to investigate the dietary practices and the health and nutritional status of the WIC ITFPS-2 children during the ninth year of life. This is a voluntary collection and FNS will use the information to inform WIC service delivery. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. 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 0584-0580. The time required to complete this information collection is estimated to average 0.1002 hours (6 minutes) 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 (0584-0580). Do not return the completed form to this address.