Healthcare Provider (Profit/Non-Profit Business)

WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2)Year 9 Extension

App_H1.Year 9 HW measurement card - English

Healthcare Provider (Profit/Non-Profit Business)

OMB: 0584-0580

Document [docx]
Download: docx | pdf




TBD

*xxxx.xx.xx.xx*



APPENDIX H1

Year 9 H/W measurement card - English


Shape1


Shape2


Shape3


Shape4


Shape5


Shape6


Shape7


Shape8


Shape9


Shape10


Shape11


Shape12


Shape13


Shape14

Shape15 Shape16 Shape17 Shape18 Shape19 Shape20 Shape21 Shape22 1600 Research Boulevard

Rockville, Maryland 20850-9973

Shape23 Shape24 Shape25 Shape26 Shape27 Shape28








Shape29



Shape30 Fold along the dotted line. Pull off adhesive strip to seal.





­Measurement Card



Shape31






Privacy Act Statement

Authority: Per §246.26 (i)(C), USDA Food and Nutrition Service is authorized to collect information to enhance the health, education, or well-being of those who use WIC services. Code of Federal Regulations. §215.11 requires WIC State and local agency directors to cooperate in the conduct of studies and evaluations. Per §246.2 of the WIC regulations, “local agencies” include public or private non-profit health or human service agencies, Indian Health Service units, and health clinics of ITOs and intertribal councils or groups.

Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration and evaluation of Special Supplemental Program for Women, Infants and Children.

Routine Use: FNS published a system of record notice (SORN) titled FNS-8 USDA/FNS Studies and Reports in the Federal Register on April 25, 1991, volume 56, pages 19078-19080, that discusses the terms of protections that will be provided to respondents.

Disclosure: Your participation in the collection of measurement data is voluntary.




Measurement Card Instructions

OMB Approval No. 0584-0580

Approval Expires: XX/XX/20XX

Shape32

This child is taking part in the WIC Feeding My Baby Study sponsored by the United States Department of Agriculture (USDA), Food and Nutrition Service. The purpose of this study is to understand health, growth, and feeding practices of children between birth and 9 years of age. To study growth, we are obtaining the height and weight measurements for these children during this critical development period. For any questions, please call [Toll-free number] (toll free).


Please complete and return this postage-paid card to Westat by mail. The parent/ caregiver will receive an incentive for bringing the child in for measurements when the card is received by Westat.


Childs First and Last Name

Childs Birthdate

Parent/Caregivers First and Last Name



To be completed by WIC/Health Care Provider staff only


Provider Type (check box)


WIC Program Healthcare Provider/Clinic Other

Provider Address Stamp OR

WIC/Health Care Provider Name Address Phone Number

Measurements


Height


in OR cm


Weight


lb oz OR kg

I (PRINT NAME) certify that the measurements were completed in the office on (DATE)

Signature of staff completing measurements Title


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-xxxx. The time required to complete this information collection is estimated to average 0.1667 hours 10 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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCrystal MacAllum
File Modified0000-00-00
File Created2022-04-29

© 2024 OMB.report | Privacy Policy