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pdfAPPENDIX D
DATA COLLECTION INSTRUMENT FOR LOCAL WIC AGENCIES
Public reporting burden for this collection of information is estimated to average 40 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. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. 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 Services, Office of Research and Analysis,
Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0484).
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
Local WIC Agency Survey
Public reporting burden for this collection of information is estimated to average 40 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. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. 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 Services, Office of Research and Analysis,
Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0484).
Thank you for participating in the FNS’ second National Survey of WIC Participants, administered
by Macro International. Please refer to the accompanying cover letter for full details of the research
effort. If you have any questions, please contact Walter Rives at 301-572-0551 or email
Walter.Rives@macrointernational.com.
This survey—along with surveys at the State and participant levels—is designed to provide FNS
with additional information on policies and program operations, above and beyond that which is
available from existing program sources. For your convenience, the survey is organized by topic.
SCREENER
S1. Does this local agency conduct certifications and recertifications of WIC applicants, or does
it serve as a purely administrative office, overseeing these functions at the clinic level?
Agency to which this survey was addressed does certifications and recertifications
CONTINUE TO SURVEY
Agency serves as a purely administrative office
Not sure -----------------------------------------------
PLEASE CONTACT WALTER RIVES
AT MACRO INTERNATIONAL TO
CLARIFY IF YOU SHOULD FILL OUT
THIS SURVEY.
PHONE: 301-572-0551
EMAIL : Walter.Rives@
macrointernational.com
Page D-1
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
Until directed otherwise, please answer all the questions as they apply to just this location of
your local agency or clinic.
CHARACTERISTICS OF LOCAL WIC AGENCY
1.
Which description most closely fits the structure in which your local agency or clinic is
located? (CHECK ONE)
Health department or medical clinic
Social services office or agency
Full service hospital
School
Site of non-profit organization
Site of religious group
Other: PLEASE SPECIFY ____________________________
2. How many rooms does the WIC program use, excluding such things as
hallways, bathrooms, kitchen, and storage closets? Please select the total
for each type of room.
Large waiting rooms/reception areas (greater than 15x15 feet)
Small waiting rooms/reception areas (15x15 feet or smaller)
Rooms, offices or cubicles where clients are seen
Large training/conference/multipurpose rooms
Small training/conference/multipurpose rooms
Administrative offices (no clients seen)
Administrative cubicles (no clients seen)
Other: PLEASE SPECIFY ______________________________
3. How many days a week, on average is the
agency open to clients/applicants?
_____ DAYS
4. How many hours per week, on average,
is the WIC agency open?
_____ HOURS
5. How many of the hours are ―extended
hours,‖ meaning they take place before 9
AM and after 5 PM?
6. Approximately how many clients are
served at the agency per month?
7. Of these, approximately what percentage
are certifications or recertifications?
_____ HOURS
__________ CLIENTS/MONTH
__________ %
Page D-2
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
8. What types of public transportation are
within a 10 minute walk (1/2 mile) of the
agency? (CHECK ALL THAT APPLY)
9. What is the most-frequent means
of transport used by WIC
applicants and participants to get
to your agency?
10. What is the second most-used
means of transport used by WIC
applicants and participants to get
to your agency?
11. How would you rate the physical
security of your local agency’s
location?
Bus
Light rail/subway/commuter train
Other
None
Private car
Taxi
Bus
Light rail/subway/commuter train
On foot
Other
Private car
Taxi
Bus
Light rail/subway/commuter train
On foot
Other
Very safe (No incidents)
Safe (Occasional minor incidents)
Unsafe (Occasional major incidents or frequent minor
incidents)
Very unsafe (Frequent major incidents)
12. Does the agency have on-site the necessary technology, equipment, supplies, etc. to do the
following tasks?
a) Enter/access client certification information via a
Yes No Don’t Know
computer?
Yes No Don’t Know
i. Is this computer networked to other
computers in the office (i.e. a shared
drive)?
Yes No Don’t Know
ii. Is this computer networked to other
agencies, clinics or the State WIC office?
b) Have internet access?
Yes No Don’t Know
c) Perform hematological tests?
Yes No Don’t Know
d) Take anthropometric measurements for
weight, BMI (body mass) and height?
Yes No Don’t Know
Page D-3
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
13. For each of the following services, please indicate if your local agency is able to offer the
service, provide information and/or make referrals in the following areas. ―Ability to make a
referral‖ means that your local agency’s involvement is required to obtain a particular service
whereas ―ability to provide information‖ means that you have only given client the information
about the problem and possibly places to go for help. (CHECK ALL THAT APPLY)
Maternal health care
Prenatal health care
Children’s health care
Prevention (e.g., immunizations) and Screenings
(e.g. vision or Early & Periodic Screening)
Breastfeeding support
Dietitian/nutrition services
Mental health services
STD (sexually transmitted diseases)
Dental
Family planning
Child care/education (e.g., Healthy Start, Head Start)
Parenting support
Employment/life skills training
Other public assistance
Environmental health/screening
Substance abuse counseling/treatment
Smoking cessation
Violence Protection/Prevention (women)
Violence Protection/Prevention (children)
OTHER: SPECIFY______________________
Offered by
WIC
Agency/Clinic
Able to
provide
information
Ability to
make a
referral
Neither
Page D-4
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
FOR ALL ITEMS WHERE REFERRALS ARE CHECKED IN Q13, ASK:
13A. In Q13, you indicated that you give referrals for certain services. For just those services where
referrals are given, please mark which type of referral is given
a. WIC client gets referral sheet to take to other organization
b. Organization is given name of WIC client to contact (with client’s knowledge)
c. Organization is notified of WIC client situation (without client’s knowledge – e.g.,
protective services – as permitted by law)
d. Other
For all services in Q13 where referrals
are given out, check all that apply.
(If no referrals given, leave blank.)
a.
b.
c.
d.
Referral
Org’l
Org. is Other
sheet
name is notified
given out
Maternal health care
Prenatal health care
Children’s health care
Prevention (e.g., immunizations) and Screenings
(e.g. vision or Early & Periodic Screening)
Breastfeeding support
Dietitian/nutrition services
Mental health services
STD (sexually transmitted diseases)
Dental
Family planning
Child care/education (e.g., Healthy Start, Head Start)
Parenting support
Employment/life skills training
Other public assistance
Environmental health/screening
Substance abuse counseling/treatment
Smoking cessation
Violence Protection/Prevention (women)
Violence Protection/Prevention (children)
OTHER:
Page D-5
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
AGENCY PROCEDURES
14. What types of identification does the agency use to verify the residency of a WIC applicant?
(CHECK ALL THAT APPLY)
Drivers license
Current utility/tax bill with address on it
Written statement from reliable third party
Checkbook
Rent receipt, mortgage receipt or lease
Other: PLEASE SPECIFY ____________________________________
Other: PLEASE SPECIFY ____________________________________
Other: PLEASE SPECIFY ____________________________________
Other: PLEASE SPECIFY ____________________________________
15. Does the agency keep a copy of documents proving adjunctive or automatic eligibility for
applicants?
Yes, physical copy
Yes, electronic copy (scanned document)
No
16. When does the start-date for a certification occur? (CHECK ONE BEST ANSWER)
When the WIC applicant first comes into the clinic
When the WIC application is filled out
When the WIC application is filled out and all supporting information provided
17. What discretion, if any, does the state use or grant to local agencies regarding certification
periods?
No additional discretion is given
The following discretion is given: (PROVIDE SUPPORTING POLICY STATEMENTS
AS APPROPRIATE )
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
18. Do certifications have to take place in person?
Yes [SKIP TO Q20]
No
Page D-6
WEB SURVEY
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
LOCAL AGENCY 1-30-09
19. If no, by what other means can WIC applicants be certified? (CHECK ALL THAT APPLY)
Phone
Mail
Fax
Other: PLEASE SPECIFY ___________________
20. Approximately what percentage of WIC applicants are given temporary certification, that is, 30
days of food instruments while the validity of their application for WIC certification is being
established?
[CIRCLE ONE ANSWER IN BOX WITH…]
20a. How confident are you in the
range entered here?
Very confident
Somewhat confident
Not very confident (i.e. a lot
of guesswork involved)
0%
1 - <10%
11 - <20%
21 - <30%
31 - <40%
41 - <50%
51 - <60%
61 - <70%
71 - <80%
81 - <90%
91 - <100%
21. Which of the following actions are designated proxies allowed to do on behalf of the WIC
participants they represent?
Get certification for the WIC applicant
Pick up food instruments
Attend educational sessions
Other: PLEASE SPECIFY ______________________________________
Not Applicable. State does not allow proxies
22. What controls are in place to ensure that a WIC applicant is not already participating in WIC at a
different location? (CHECK ALL THAT APPLY)
Applicant must show identification
Applicant must submit proof of current residence
Computer checks system based on applicant name
Computer checks system based on Social Security number
Other procedure: PLEASE DESCRIBE _______________________
Page D-7
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
23. Of applicants new to WIC, what percentage is denied certification?
[CIRCLE ONE ANSWER IN BOX WITH…]
23a. How confident are you in the
range entered here?
Very confident
Somewhat confident
Not very confident (i.e. a lot
of guesswork involved)
<10%
11 - <20%
21 - <30%
31 - <40%
41 - <50%
51 - <60%
61 - <70%
71 - <80%
81 - <90%
91 - <100%
24. Of WIC participants seeking recertification, what percentage is denied certification?
[CIRCLE ONE ANSWER IN BOX WITH…]
24a. How confident are you in
the range entered here?
Very confident
Somewhat confident
Not very confident (i.e. a lot
of guesswork involved)
<10%
11 - <20%
21 - <30%
31 - <40%
41 - <50%
51 - <60%
61 - <70%
71 - <80%
81 - <90%
91 - <100%
25. Please specify the percentage of denials that are attributable to the following eligibility problems.
It is possible the percentages may sum to more than 100% as applicants may be denied that for
more than one reason.
Insufficient identification
______%
Income ineligibility
______%
Nutritional ineligibility
______%
Residency ineligibility
______%
Category ineligibility (i.e. not
pregnant, child over 5 years, etc.)
______%
Other: PLEASE SPECIFY
_______________________
______%
25a. How confident are you in the
percentages entered here?
Very confident
Somewhat confident
Not very confident (i.e. a lot
of guesswork involved)
Page D-8
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
26. Does the agency keep information on denied applicants?
Yes
No [SKIP TO Q28]
27. What information on Denied Applicants do you retain and how is it retained?
a. Information Retained
b. How Retained
c. Where Retained
(CHECK ALL THAT APPLY)
(CHECK ALL THAT APPLY)
(CHECK ALL THAT APPLY)
Name of applicant
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
Address
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
Phone number
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
WIC applicant category
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
Reason for denial
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
Date of application
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
Date of denial
Paper copy only
Electronic copy only
Both paper and electronic
WIC State Agency
Your Local Agency
Sites/Clinics
28. Does the agency send an official letter of denial to applicants who are denied eligibility for WIC?
Yes
No
Page D-9
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
29. Can an applicant be screened and denied eligibility by telephone?
Yes
No [SKIP TO Q31]
30. For which reasons can an applicant be screened and denied eligibility by telephone? (CHECK
ALL THAT APPLY)
Insufficient identification
Income eligibility
Nutritional eligibility
Residency eligibility
Category eligibility
Other: PLEASE SPECIFY:________________________________
NUTRITION SERVICES
31. What nutrition services are offered by your local agency? (CHECK ALL THAT APPLY)
One-on-one counseling
Group educational sessions
Internet-based nutrition education for clients to use
Other: PLEASE SPECIFY_______________________
32. Who provides these nutrition services? (CHECK ALL THAT APPLY)
WIC Director or Clinic Supervisor
Registered Dietitians
Degreed/Licensed Nutritionists
Trained Nutrition Paraprofessional
Registered Nurses/Physicians Assistants
Physicians
Social Workers/ Psychologists/ Therapists
Other Health Professionals not listed here
Other Non-Health Professionals not listed here
Administrative/clerical/support staff
Peer Counselors
33. On average, how much time is spent giving
nutrition education to an adult client during the
certification process?
[DROP-DOWN BOX:]
None
<5 minutes
5 - <10 minutes
10 - <20 minutes
20 - <30 minutes
30 - <45 minutes
45 - <60 minutes
60 minutes or more
Page D-10
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
34. In a given 3-month period, on average, how
much time is spent giving nutrition education
to an adult client during follow-up visits
(excluding the initial certification)?
[DROP-DOWN BOX:]
None
<10 minutes
10 - <20 minutes
20 - <30 minutes
30 - <45 minutes
45 - <60 minutes
60 - <90 minutes
90 minutes or more
35. What percentage of infants are certified off-site (e.g. in the hospital)?
_______ %
36. What types of outreach does your local agency do in, or with, hospitals to help bring qualified
infants into the WIC program? (CHECK ALL THAT APPLY)
Agency staff visit currently-certified and prospective WIC mothers in the hospital
Agency provides general information and/or specific forms to the hospital for distribution
Agency staff provide pregnant mothers with WIC forms (for their infants) for hospital
physicians to fill out
Agency joins with other social service agencies to provide a place at the hospital where
prospective clients can shop services, all in one place
Other: PLEASE SPECIFY
From this point forward, please answer the remaining 16 questions as they apply to the WIC
local agency in its entirety, including all clinics, satellites and mobile units.
LOCAL AGENCY ORGANIZATION
37. How would you describe the relationship of your WIC local agency to the WIC State agency?
Your local agency is… (CHECK ONE)
part of State agency
a local government entity administering the WIC program
a non-profit organization that has been contracted to run the WIC program
not a local agency, but rather a clinic under a local agency
Other: PLEASE SPECIFY________________________
Page D-11
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
38. Please record the number of other WIC sites that operate under the authority of this local agency,
by type.
___ Clinics (defined as a permanent location assigned to the WIC program)
___ Satellites (defined as a location such as a school, church or town hall that is only
temporarily assigned the WIC program each week. WIC staff must carry their own
files and equipment to the site each week)
___ Mobile Units (a vehicle assigned to the WIC program that may make multiple stops)
39. To what extent are certification services provided by your local agency at the various sites you
specified in the previous question?
[WEB SURVEY WILL SHOW CLINICS, SATELLITES AND/OR MOBILE UNITS
COLUMN ONLY IF RESPONDENT HAS ANSWERED >0 IN Q38.]
Conducts certifications
Performs blood testing
Takes anthropometric
measurements for
height, weight and body
mass index (BMI)
Conducts nutrition
counseling
Offers other educational
seminars (e.g. on
breastfeeding)
Distributes food
instruments
Provides referrals to
other services
Has access to WIC
participant records
electronically
Stores paper copies of
the WIC participant
records
Local
Agency
Clinics
Satellites
Mobile Units
Agency
does this
All Some None
can do can do can do
All Some None
can can do can
do
do
All Some None
can can do can
do
do
Page D-12
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
40. What is the distribution and average allocation of Nutrition Services and Administration (NSA)
funds across the following functions?
______ % Certification and re-certification
______ % Nutrition education
______ % Breastfeeding promotion and support
______ % Administration
100 % [TOTAL SHOULD SUM TO 99-101%.]
STAFF & CASELOAD
41. How many staff members
work for the WIC program at
your local agency or clinic on
a full-time or part-time basis?
Number of
Number of
full-time staff part-time staff
(working
(working
32- 40+
<32 hours/wk)
hours/wk)
42. Of the total,
what percentage
have worked at
the agency/clinic
less than 2 years
a) WIC Director or Clinic
Supervisor
______%
b) Office Manager
______%
______%
______%
______%
______%
______%
______%
______%
c) Administrative Support Staff
d) Certification Specialist
e) Registered Dietitian
f) Degreed/Licensed Nutritionist
g) Trained Nutrition
Paraprofessional
h) Registered Nurse/Physicians
Assistant
i) Physician
j) Social Worker/ Psychologist/
Therapist
k) Other Professional (nonmedical)
l) Other: PLEASE SPECIFY
____________________
TOTAL STAFF
______%
______%
______%
______%
Page D-13
WEB SURVEY
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
LOCAL AGENCY 1-30-09
43. In all, what is the number of full-time equivalent (FTE) staff who work at your local WIC
agency or clinic? (IN CALCULATING, NOTE THAT IF THE STANDARD WORK WEEK IS 35-40
HOURS, AN FTE COULD BE COMPOSED OF 1 FULL TIME EMPLOYEE OR TWO OR MORE PART TIME
EMPLOYEES WHO, COMBINED, WORK THAT NUMBER OF HOURS.)
_____ FTE Staff
44. What difficulties are faced in retaining, recruiting and hiring staff at your local agency?
(CHECK ALL THAT APPLY)
Salaries not competitive
Benefits not competitive
Minimal training and job growth offered
Workload too great
Location of local agency unsafe
Location of local agency hard to get to
Physical space occupied by local agency crowded
Low employee morale throughout agency
Lack of support for WIC program from State
Limited career path or opportunities for promotion
Required skillset lacking in prospective employees
Other: PLEASE SPECIFY______________________
None of the above
45. Check off any positions for which your local agency is experiencing moderate or acute
staffing shortages? (CHECK ALL THAT APPLY)
Administrative/clerical/support staff
Registered Dietitian
Degreed/Licensed Nutritionist
Trained Nutrition Paraprofessional
Registered Nurses/Physicians Assistant
Physician
Social Worker/ Psychologist/ Therapist
Other Professional
Other: PLEASE SPECIFY __________
None of the above
Page D-14
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
46. What percentage of WIC applicants and certificants coming to the agency do NOT speak
English well enough to communicate about eligibility, procedures, nutrition, breastfeeding and
services?
0%
1-5%
6-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%
46a. How confident are you in the
range entered here?
Very confident
Somewhat confident
Not very confident (i.e. a lot of
guesswork involved)
47. What foreign languages are offered by local agency staff? (CHECK ALL THAT APPLY)
NONE
Arabic
Cambodian
Cantonese/Mandarin
Farsi
French/Creole
Fulani
Hindi
Hmong
Khmer
Korean
Laotian
Portuguese
Punjabi
Russian
Somali
Spanish
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other: SPECIFY _________
48. Approximately what percentage of your WIC population (applicants, participants, and
proxies) are not served by your combined language capabilities?
_______ %
48a. How confident are you in the
percentage entered here?
Very confident
Somewhat confident
Not very confident (i.e. a lot of
guesswork involved)
[IF Q48 MARKED < 10%, SKIP TO Q50]
Page D-15
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
49. In what languages does the agency need further support to serve the WIC population?
(CHECK ALL THAT APPLY)
Arabic
Cambodian
Cantonese/Mandarin
Farsi
French/Creole
Fulani
Hindi
Hmong
Khmer
Korean
Laotian
Portuguese
Punjabi
Russian
Somali
Spanish
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other: SPECIFY _________
PARTICIPANT CHARACTERISTICS
Thinking of the typical WIC participants served by your local agency each month, please give the
percentage that fall into the following demographic areas. (PLEASE ROUND PERCEN-TAGES TO
NEAREST WHOLE NUMBER. PERCENTAGES MAY TOTAL 99-101% DUE TO
ROUNDING)
50. CATEGORY
___%
___%
___%
___%
___%
Pregnant
Breastfeeding
Postpartum
Infants
Children
100 % TOTAL
51. ETHNICITY
___% Hispanic or Latino
___% Not Hispanic or Latino
100 % TOTAL
52. RACE
___%
___%
___%
___%
___%
___%
American Indian or Alaska Native
Asian American
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multiracial (Two or more of the above)
100 % TOTAL
Page D-16
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
WEB SURVEY
LOCAL AGENCY 1-30-09
53. OTHER CHARACTERISTICS
a. What percentage of participants are migrant farmworkers
b. What percentage of participants are homeless
_____ %
_____ %
THIS MARKS THE END OF THE SURVEY.
THANK YOU VERY MUCH FOR YOUR TIME!
IF YOU HAVE ANY COMMENTS THAT WERE NOT COVERED IN THE SURVEY, YOU MAY
PROVIDE THEM BELOW.
_______________________________________________________________________________
Page D-17
| File Type | application/pdf |
| Author | Walter.N.Rives |
| File Modified | 2009-02-02 |
| File Created | 2009-01-30 |