OMB Control#: 0584-0548
Expiration Date: xx/xx/20xx
Appendix C6: Peer Counseling Refusal/Withdrawal Form
Peer Counseling Refusal/ Withdrawal Form
OMB Clearance Number: 0584-0548 Expiration Date: xx/xx/20xx
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 0584-0548. The time required to complete this information collection is estimated to average 3 minutes per response. If you have any comments concerning the accuracy of time estimates or suggestions for improving this form, please contact: U. S. Department of Agriculture, Food and Nutrition Service, Office of Research & Analysis, Room 1014, Alexandria, VA 22302.
Instructions to Peer Counselor:
If a WIC participant withdraws from the Loving Support Peer Counseling program and she had enrolled in the WIC Peer Counseling Study, please complete PAGE 1 of this form.
If you attempted, but were unable, to meet in-person with a WIC participant enrolled in the study, please complete PAGE 2 of this form.
Do not write the WIC Participant’s name anywhere on this form.
Withdrawal from Breastfeeding Peer Counseling
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Participant’s Study ID |
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Today’s Date |
dd/ month /yyyy |
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Due date of infant (or birthdate) |
dd/ month /yyyy |
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Name of person completing this form: |
Do not write WIC participant’s name here |
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Reason(s) given for withdrawing from breastfeeding peer counseling: Check all that apply |
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Too busy |
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Transportation difficulty |
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Perinatal death/pregnancy terminated |
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Mother is sick, not feeling well |
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Does not want to breastfeed her baby |
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Unknown/no reason given/no contact made |
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Other reason(s), describe: |
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Please give this form to [Name of local WIC agency Study Contact].
Peer Counseling Meeting Refusal
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Participant’s Study ID |
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Today’s Date |
dd/ month /yyyy |
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Birth date of infant |
dd/ month /yyyy |
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Peer Counselor Name |
Do not write WIC participant’s name here |
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Outcome of attempt to meet in-person |
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No show or no answer |
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Said she does not want an in-person meeting |
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Requested a new meeting time |
Next in-person meeting: |
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Requested phone call |
dd/month/yyyy |
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Where did you attempt to meet with this WIC participant? Mark one answer |
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At her home |
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At a WIC clinic |
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Other location, specify: |
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Reason(s) given for declining the in-person meeting: Check all that apply |
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Not a good time right now |
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Transportation difficulty |
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Baby is sick or in the hospital |
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Mother is sick, not feeling well |
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Baby sleeping |
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Forgot about appointment |
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Does not want to breastfeed |
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Does not want breastfeeding assistance – FILL OUT PEER COUNSELING CLOSURE FORM |
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Unknown/no reason given/no contact made |
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Other reason(s), describe: |
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Follow-up planned: |
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None |
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Will attempt to reschedule in-person meeting |
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Will attempt telephone peer counseling contact |
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Call to confirm withdrawal from peer counseling program |
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Other, describe: |
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Please give this form to [Name of local WIC agency Study Contact].
File Type | application/msword |
File Title | DECLINE form |
Author | EpsteinC |
Last Modified By | Carter Epstein |
File Modified | 2011-05-13 |
File Created | 2011-05-13 |