OMB
Control Number: 0584-XXXX
|
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB 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 45 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. |
Nutrition Education Survey Help Desk If you have any problems completing the survey, please contact:[Toll-free phone number][Email address] |
For all questions, nutrition education includes breastfeeding education.
How many days per month does the site provide WIC nutrition education services? (Count days when any form of nutrition education is provided. If it varies from month to month, enter the number of days WIC nutrition education services were provided last month.)
Number of days: _____
Are participants at the site classified into nutrition risk levels (e.g., high risk, not high risk)?
Yes
No
What, if any, modifications to nutrition education does the site make based on participant’s risk levels or nutrition risks? For this question, “high risk” includes participants identified as high risk and/or participants with nutrition risks requiring special attention. (Select all that apply.)
There are no modifications to nutrition education for high-risk participants.
High-risk participants receive more nutrition education contacts.
High-risk participants receive nutrition education from a dietitian, nutritionist or other health professional.
High-risk participants are given longer appointment times.
High-risk participants receive one-on-one counseling instead of group sessions or other types of education.
High-risk participants receive more detailed and individualized care plans.
There is more follow-up on referrals for high-risk participants.
Other (describe): _____________________________________________
In the first column, enter the number of nutrition education contacts the site offers (i.e., makes available) during a certification period for each participant category and time period. While the number of contacts varies based on individual needs, enter the number that is offered to the majority of participants in the category. (Count all contacts beginning with the certification visit; for example, if prenatal women who enroll in the 1st trimester are offered nutrition education at their initial visit and two more contacts during their prenatal certification period, enter “3.” Enter NA for any category/time period that is not applicable at the site.)
In the second column, enter the estimated percentage of participants who receive that number of nutrition education contacts during their certification period. (Please estimate based on your experience. You do not need to run a report or review participant records to answer this question.)
Participant Category and Time Periods |
Number of Nutrition Education Contacts Site Offers during Certification Period |
Estimated Percentage of Participants who Receive this Number of Contacts |
Participants who are NOT high risk |
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Prenatal woman, enrolling in 1st trimester |
__ |
__ % |
Prenatal woman, enrolling in 2nd trimester |
__ |
__ % |
Prenatal woman, enrolling in 3rd trimester |
__ |
__ % |
Breastfeeding woman, 6-month certification period |
__ |
__ % |
Breastfeeding woman, 12-month certification period |
__ |
__ % |
Postpartum woman, not breastfeeding |
__ |
__ % |
Infant, 6-month certification period |
__ |
__ % |
Infant, 12-month certification period |
__ |
__% |
Child, 6-month certification |
__ |
__ % |
Child, 12-month certification |
__ |
__ % |
Participants who are high risk and/or have nutritional risks requiring special attention |
||
Prenatal woman, enrolling in 1st trimester |
__ |
__ % |
Prenatal woman, enrolling in 2nd trimester |
__ |
__ % |
Prenatal woman, enrolling in 3rd trimester |
__ |
__ % |
Breastfeeding woman, 6-month certification period |
__ |
__ % |
Breastfeeding woman, 12-month certification period |
__ |
__ % |
Postpartum woman, not breastfeeding |
__ |
__ % |
Infant, 6-month certification period |
__ |
__ % |
Infant, 12-month certification period |
__ |
__% |
Child, 6-month certification period |
__ |
__ % |
Child, 12-month certification period |
__ |
__ % |
During what types of visits does the site provide nutrition education contacts? (Select all that apply.)
Certification visit (e.g., enrollment, recertification)
Mid-certification visit (e.g., prenatal trimester visit, infant/child mid-certification, breastfeeding mid-certification)
Secondary education follow-up visit (e.g., group classes, food issuance/pick-up, breastfeeding follow-up, low risk follow-up)
High-risk follow-up visit (e.g. nutritionist visit, nutrition counseling visit, high-risk group classes)
Other visits (describe):
Programming Note: For Question 6, display only the types of visits selected for Question 5. If “certification visit” was selected, display both “enrollment certification” and “recertification.” |
What methods are used to provide nutrition education? (Select all methods that are used for each type of visit.)
Method |
Enrollment Certification |
Recertification |
Mid-certification |
Secondary Education |
High-Risk |
Other |
One-on-one counseling: Face to face (in WIC site) |
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One-on-one counseling: Telephone |
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One-on-one counseling: Video conferencing |
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Group education sessions |
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Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet) |
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Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules) |
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Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules) |
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Programming Note: For Question 7, display only the types of visits selected for Question 5. If “certification visit” was selected, display both “enrollment certification” and all three types of “recertification.” |
On average, how much time do staff members who provide nutrition education at the site spend providing nutrition education during each of the following types of WIC visits? Do not include time spent on eligibility (e.g., income and residency) or assessment (e.g., weighing/measuring, blood work, reviewing nutrition questionnaires).
Type of Visit |
Less
than 5 |
5–10 |
11–20 Min |
21–30 |
31–45 |
46–60 |
More than 60 Min |
Don’t Know |
Enrollment Certification |
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Recertification
— |
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Recertification
— |
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Recertification
— |
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Mid-certification |
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Secondary education follow-up (individual) |
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Secondary education follow-up (group) |
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High-risk follow-up |
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Other |
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Which best describes the staff members who provide nutrition education at the site? (Select one response.)
All of them work only for WIC.
All of them work for WIC and for other programs or services (e.g., immunizations, family planning) offered at the site.
Some of them work only for WIC and some work for WIC and other programs or services offered at the site.
For each job classification/type of staff, enter the number of staff who currently provide nutrition education at the site who work full time and the number who work part time. (If a staff member works 32 or more hours/week on WIC, count them in the Full-Time Staff column and if less than 32 hours/week on WIC, count them in the Part-Time Staff column appropriate for the number of hours they work per week. If a staff member performs more than one role, count them only once in the job classification/type for their primary role.)
Job Classification/Type of Staff |
Number of Full-Time Staff (work on WIC activities 32 or more hours per week) |
Number of Part-Time Staff (work on WIC activities 21–31 hours per week) |
Number of Part-Time Staff (work on WIC activities 20 or fewer hours per week) |
WIC director/coordinator |
___ |
___ |
___ |
Site/clinic supervisor |
___ |
___ |
___ |
Registered dietitian (RD) |
___ |
___ |
___ |
Degreed nutritionist, not RD |
___ |
___ |
___ |
Trained nutrition paraprofessional (e.g., nutrition assistant, nutrition aid, competent paraprofessional authority, diet technician, social services technician) |
___ |
___ |
___ |
Nurse |
___ |
___ |
___ |
Nutrition education coordinator |
___ |
___ |
___ |
Administrative/clerical/support staff |
___ |
___ |
___ |
Lactation consultant/WIC-designated breastfeeding expert |
___ |
___ |
___ |
Breastfeeding coordinator |
___ |
___ |
___ |
Breastfeeding peer counselor |
___ |
___ |
___ |
Other: _______________ |
___ |
___ |
___ |
Total |
___ |
___ |
___ |
For
question 9 and all subsequent survey questions that include a
response option of “other” in a table, display the
following question when “other” is selected as a
response: You
selected “other” as a response to the question above.
Please enter an explanation of “other”
in this box. [Include a text entry box allowing for entry of 200
characters.]
How many years have staff members who provide nutrition education at the site worked for WIC? (Count both full-time and part-time staff and count each staff member only one time for the total number of years they have worked for WIC. Include time worked at this site or local agency/program and time at other WIC sites or local agencies.)
Number of Years Worked at WIC |
Number of Staff who Provide Nutrition Education |
Less than 1 Year |
__ |
1–2 Years |
__ |
3–6 Years |
__ |
7–10 Years |
__ |
11–20 Years |
__ |
More Than 20 Years |
__ |
Total |
__ |
What is the educational level of individual staff members who provide nutrition education at the site? (Count both full-time and part-time staff and count each staff member only one time for the highest degree they have received.)
Education Level (Highest Degree Received) |
Number of Staff who Provide Nutrition Education |
High school diploma or GED |
__ |
Associate’s degree |
__ |
Bachelor’s degree |
__ |
Graduate degree |
__ |
Unknown |
__ |
Total |
__ |
How many of the staff members who provide nutrition education at the site have one or more of the credentials* listed below? (If a staff member has more than one credential, count them for each credential they have; for example, if a staff member is both an RD and a LD/LN, count them in each credential group. If no staff members have any of these credentials, select “None of these credentials” box).
Credentials |
Number of Staff who Provide Nutrition Education |
Registered Dietitian (RD) |
__ |
Licensed Dietitian/Nutritionist (LD/LN) |
__ |
Dietetic Technician, Registered (DTR) |
__ |
Registered Nurse (RN) |
__ |
Licensed Practical Nurse (LPN) |
__ |
International Board Certified Lactation Consultant (IBCLC) |
__ |
Certified Lactation Consultant/Certified Lactation Educator/Certified Lactation Educator & Counselor (CLC/CLE/CLEC) |
__ |
Certified Medical Assistant (CMA) |
__ |
None of these credentials |
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*A credential is a certification from a professional association or training program.
What is the ethnicity of staff members who provide nutrition education at the site? (If you do not know the ethnicity of a staff member, count them in the “Unknown” category.)
Hispanic or Latino Ethnicity |
Number of Staff who Provide Nutrition Education |
Hispanic or Latino |
__ |
Not Hispanic or Latino |
__ |
Unknown |
__ |
Total |
__ |
What is the race of staff members who provide nutrition education at the site? (Staff members may be included in more than one category. If you do not know the race of a staff member, count them in the “Unknown” category.)
Race |
Number of Staff who Provide Nutrition Education |
American Indian or Alaska Native |
__ |
Asian |
__ |
Black or African American |
__ |
Native Hawaiian or other Pacific Islander |
__ |
White |
__ |
Unknown |
__ |
How many staff members provide nutrition education in a language other than English? (Do not include interpreters and translators.)
Number of staff: _______
Programming Note: If Question 15 is “0” or blank, then skip Question 16. The selection for Question 16 will be a drop-down list allowing for multiple selections. |
Other than English, what languages are spoken by staff who provide nutrition education at the site? (Select all that apply.)
Spanish
Arabic
American Sign Language
Cambodian/Khmer
Cantonese/Mandarin
Farsi
French/Creole
Fulani
Hindi
Hmong
Korean
Laotian
Portuguese
Punjabi
Russian
Somali
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other (describe):
In addition to WIC, which of the following services are available at or near the site? (Select all that apply.)
Children’s health care
Dental services
Environmental health/screening
Family planning services
Lead screening
Maternal/prenatal health care
Parenting support
Prevention and screening services (e.g., vision, early and periodic screening, immunizations)
Sexually transmitted disease services
Smoking cessation
There are no other services available at this site.
Other (describe)
What settings at the site are used for one-on-one counseling? (Select all that apply.)
Private room (full walls and door, e.g., office, exam/lab room)
Modular office/cubicle (with full or partial walls)
Area with movable partitions separating it from other space
Open area with no partitions and staff at desks that are arranged for privacy
Open area with no partitions and staff at tables (e.g., waiting room, community center room)
Other (describe):
Programming Note: Display Question 19 only if “Group education sessions” was selected as a method in Question 6. |
What settings at the site are used for group education sessions? (Select all that apply.)
Designated room or space used predominately for group education
Multi-purpose room used for group education and other meetings, but not a waiting room (e.g., conference room, auditorium)
General open area (e.g., waiting room, open room where all WIC activities take place)
Private room used for both one-on-one counseling and group education
Other (describe):
Which, if any, of these rooms/areas are available at or near the site? (Select all that apply.)
Designated room/area where breastfeeding education is provided
Kitchen/area for cooking classes or recipe preparation demonstrations
Room/area for nutrition education activities with children
Room/area for providing WIC orientation to families
Room/area for viewing nutrition education or breastfeeding videos
None of the above
Which, if any, of these equipment items or materials does the site have available for providing nutrition education? (Select all that apply.)
Bulletin boards for nutrition education information
Computer, kiosk, or tablet computer for nutrition education
Display tables with nutrition information
DVD player and TV for showing nutrition education information
Equipment for teaching cooking classes (e.g., stove, refrigerator)
Equipment for simple food tasting (e.g., blender, crock pot)
Nutrition education curricula or materials targeted to children (e.g., Sesame Workshop, kids’ camp)
Nutrition newsletters
Rack/table/stand with written nutrition education materials for participants to select
Other (describe):
None of the above
About what percentage of participants served at the site speak a language other than English as their primary language? (Please estimate if this information is not readily available. You do not need to run a report or review participant records to answer this question.)
None
1–5%
6–10%
11–30%
31–50%
51–70%
71–90%
91–100%
Programming Note: If response to Question 22 is “None,” then skip Question 23. The list of response options for Question 23 will be a drop-down list allowing for multiple selections. |
Other than English, what languages are spoken by participants served at the site? (Select all that apply.)
Spanish
Arabic
American Sign Language
Cambodian/Khmer
Cantonese/Mandarin
Farsi
French/Creole
Fulani
Hindi
Hmong
Korean
Laotian
Portuguese
Punjabi
Russian
Somali
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other (describe):
Did you complete the Local Agency Survey for the local agency/program that oversees this site?
Yes
No
Programming Note: If “Yes” is selected for Question 24, then skip Questions 25 through 29. |
Which job titles or roles do you have? (Select all that apply.)
WIC director/coordinator
Site/clinic supervisor
Registered dietitian (RD)
Degreed nutritionist, not RD
Trained nutrition paraprofessional (e.g., nutrition assistant, nutrition aid, competent paraprofessional authority, diet technician, social services technician)
Nurse
Nutrition education coordinator
Administrative/clerical/support staff
Lactation consultant/WIC-designated breastfeeding expert
Breastfeeding coordinator
Breastfeeding peer counselor
Other (describe):
Programming Note: If only one option is selected for Question 25, then skip Question 26. |
Which best describes your primary role in the WIC Program? (Select one response.)
WIC director/coordinator
Site/clinic supervisor
Registered dietitian (RD)
Degreed nutritionist, not RD
Trained nutrition paraprofessional
Nurse
Nutrition education coordinator
Administrative/clerical/support staff
Lactation consultant/WIC-designated breastfeeding expert
Breastfeeding coordinator
Breastfeeding peer counselor
Other (describe):
What is the highest degree you have completed?
High school diploma or GED
Associate’s degree
Bachelor’s degree
Graduate degree
Which, if any, of the following credentials do you have? (Select all that apply.)
Registered Dietitian (RD)
Licensed Dietitian/Nutritionist (LD/LN)
Dietetic Technician, Registered (DTR)
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
International Board Certified Lactation Consultant (IBCLC)
Certified Lactation Consultant/Certified Lactation Educator/Certified Lactation Educator & Counselor (CLC/CLE/CLEC)
Certified Medical Assistant (CMA)
Other (describe):
No credentials
How many years have you worked for the WIC Program? (Include time at this site or local agency and other WIC experience.)
Less than 1 year
1–3 years
4–6 years
7–10 years
11–20 years
More than 20 years
As part of your job, do you design and/or oversee nutrition education at the site?
Yes
No
As part of your job, about what percentage of your time each month is spent providing nutrition education to WIC participants?
Less than 25%
25–49%
50–74%
75–100%
Please use the space below to share a brief description of any special nutrition education activities or approaches used at the site.
Programming Note: Please provide a text field with sufficient space for an open-ended, 8-line response (800-character response) for Question 32. |
Thank you for completing the Site Survey for the WIC Nutrition Education Study!
Instructions: This is an optional form you can use to gather information about the staff at the site that provide nutrition education. Listed below each column heading is the corresponding survey question. An example of how to complete the form is shown in the first line.
First Name and Last Initial of Staff at the Site who Provide Nutrition Education |
Number of Years Worked at WIC Question 10 (Select one) |
Education Level – Highest Degree Received Question11 (Select one) |
Credentials Question
12 |
Ethnicity Question 13 (Select one) |
Race Question14 |
Languages Spoken Other than English Question
16 |
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Less than 1 year |
1 – 2 years |
3 – 6 years |
7 – 10 years |
11 – 20 years |
More than 20 years |
High school or GED |
Associate’s Degree |
Bachelor’s Degree |
Graduate Degree |
Unknown |
Registered Dietitian (RD) |
Licensed Dietitian/Nutritionist (LD/LN) |
Dietetic Technician, Registered (DTR) |
Registered Nurse (RN) |
Licensed Practical Nurse (LPN) |
International Board Certified Lactation Consultant (IBCLC) |
Certified Lactation Consultant/Certified Lactation Educator/Certified Lactation Educator & Counselor (CLC/CLE/CLEC) |
Certified Medical Assistant (CMA) |
None of these credentials |
Hispanic or Latino |
Not Hispanic or Latino |
Unknown |
American Indian or Alaska Native |
Asian |
Black or African American |
Native Hawaiian or Other Pacific Islander |
White |
Unknown |
Spanish |
All other languages (specify) |
Employee A. |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | scc |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |