WIC NE State & Local - Phase I

APPENDIX C.4:
Site Paper Survey Version 2—English

OMB Control Number: 0584-XXXX
Expiration date: XX/XX/XXXX

WIC Nutrition Education Study

Site Survey (Version 2)

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.

Thank you for completing the Site Survey for the WIC Nutrition Education Study (NEST). This survey is being conducted for the USDA, Food and Nutrition Service (FNS) to collect information that will provide a description of how WIC sites provide nutrition education to participants. This site was randomly selected as part of a group of about 2,000 sites that represent all WIC sites in the nation. Your responses to the survey will be combined with responses from the other sites to develop a comprehensive picture of the methods, staffing, resources, and space used to deliver nutrition education in local WIC sites. Your input is critical in achieving the study’s goal of providing a comprehensive description of WIC nutrition education. The information you provide will help strengthen and enhance WIC nutrition education efforts and highlight the efforts across the country to promote healthy eating and physical activity practices among WIC participants.

Local agencies/programs, sites, and individual respondent names will not be identified in any study reports or publications. Although survey responses will be identifiable to FNS, the responses will not be used for compliance or monitoring activities.

Please complete the survey by MM/DD/YYYY.

Most questions include a box  for you to check response(s). A few questions require that you enter numbers or text responses. Please use blue or black ink to complete the survey. The survey will take about 45 minutes to complete. We recommend that you review the questions before beginning the survey so that you can obtain any information needed to respond or ask other staff at the site to assist with answering some of the questions.

Nutrition Education Survey Help Desk

If you have any problems completing the survey, please contact:

[Toll-free phone number]

[Email address]

Nutrition Education Contacts and Methods

For all questions, nutrition education includes breastfeeding education.

1. 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: _____

2. Are participants at the site classified into nutrition risk levels (e.g., high risk, not high risk)?

• Yes

• No

3. 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. (Check 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):_______________________________________

4. 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 1^st 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
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

5. During what types of visits does the site provide nutrition education contacts? (Check 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):

6. What methods are used to provide nutrition education? (Check all methods that are used for each type of visit. Check NA if the site does not provide this type of visit.)

Method	Enrollment Certification	Recertification	Mid-certification	Secondary Education	High-Risk	Other
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						
Type of visit not provided (NA)						

7. 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). (Check NA if the site does not provide this type of visit.)

Type of Visit	Less than 5 Min	5–10 Min	11–20 Min	21–30 Min	31–45 Min	46–60 Min	More than 60 Min	NA	Don’t Know
Enrollment Certification									
Recertification — Not high risk, 1 person									
Recertification — High risk, 1 person									
Recertification — 2 or more family members									
Mid-certification									
Secondary education follow-up (individual)									
Secondary education follow-up (group)									
High-risk follow-up									
Other									

Nutrition Education Staff

The next questions ask about the staff members at the site who provide nutrition education. If the number of these staff varies on different days, respond about staffing for a “typical” day or use the most common/frequent staffing pattern for the site. Count staff who provide nutrition education using any method. Do not include translators or interpreters who assist nutrition educators.

8. Which best describes the staff members who provide nutrition education at the site? (Check 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.

9. 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

Nutrition Education Practices

The next questions ask about the nutrition education practices and approaches used at the site.

1. During certification visits (enrollment or recertification), how often does the site use the methods listed below to provide nutrition education? (Check one response for each method.)

• Check the box and go to Question 11 if the site does not provide certification visits.
  
  
  

Method	Never	Rarely (<10%)	Occasionally (11–39%)	Some-times (40–59%)	Often (60–89%)	Almost Always (≥90%)
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						

11. During mid-certification visits, how often does the site use the methods listed below to provide nutrition education? (Check one response for each method.)

• Check the box and go to Question 12 if the site does not provide mid-certification visits.
  
  
  

Method	Never	Rarely (<10%)	Occasionally (11–39%)	Some-times (40–59%)	Often (60–89%)	Almost Always (≥90%)
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						

12. During secondary education follow-up visits, how often does the site use the methods listed below to provide nutrition education? (Check one response for each method.)

• Check the box and go to Question 13 if the site does not provide secondary education follow-up visits.
  
  
  

Method	Never	Rarely (<10%)	Occasionally (11–39%)	Some-times (40–59%)	Often (60–89%)	Almost Always (≥90%)
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						

13. During high-risk follow-up visits, how often does the site use the methods listed below to provide nutrition education? (Check one response for each method.)

• Check the box and go to Question 14 if the site does not provide high-risk follow-up visits.
  
  
  

Method	Never	Rarely (<10%)	Occasionally (11–39%)	Some-times (40–59%)	Often (60–89%)	Almost Always (≥90%)
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						

14. During other types of visits (not including certification, mid-certification, secondary education follow-up, and high-risk follow-up visits), how often does the site use the methods listed below to provide nutrition education? (Check one response for each method.)

• Check the box and go to Question 15 if the site does not provide other types of visits.
  
  
  

Method	Never	Rarely (<10%)	Occasionally (11–39%)	Some-times (40–59%)	Often (60–89%)	Almost Always (≥90%)
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						

15. How does the site follow up with participants about their goals or concerns discussed during nutrition contacts (e.g., breastfeeding issues, weight-related goals)? (Check all that apply.)

• Follow-up occurs at subsequent WIC visits

• Telephone calls

• Emails

• Text messages

• Video conferencing

• Other (describe):

16. How does the site provide nutrition education to participants who do not speak English? (Check all that apply.)

• Not applicable--the site only has English-speaking participants.

• The site has bilingual WIC staff members who provide nutrition education.

• The site has interpreters or translators available.

• Site staff members use language line/phone interpreter service.

• Site staff members use translation program on the computer.

• Participants bring family member or friend to interpret.

• Participants use translated self-study or internet modules.

• Other (describe):

17. In the first column, check “Yes” or “No” to indicate if staff members who provide nutrition education at the site have received training on the topic during the past 12 months. In the second column, for each topic that you check “Yes,” estimate the number of hours of training on that topic per staff member during the past 12 months. Include all types of training (e.g., workshops, conferences, presentations at staff meetings).

    Topic	Included in Training during Past 12 Months?	If Yes, Estimated Number of Training Hours per Staff Member in Past 12 Months
    Breastfeeding	 Yes  No
    Prenatal nutrition	 Yes  No
    Infant nutrition	 Yes  No
    Child nutrition	 Yes  No
    Value Enhanced Nutrition Assessment [VENA] skills	 Yes  No
    Participant or learner-centered education	 Yes  No
    Motivational interviewing	 Yes  No
    Emotion-based counseling	 Yes  No
    Group facilitation skills (e.g., facilitated group discussion)	 Yes  No
    Weight and growth issues (prenatal weight gain, infant/child growth, and weight gain)	 Yes  No
    Other nutrition topics	 Yes  No

18. How are discussion topics determined for most of the one-on-one counseling sessions at the site? (Choose up to three methods and rank them by entering “1” for the method used most often, “2” for the method used next most often, and “3” for the method used next most often.)

____ The staff member chooses the most appropriate topic(s).

____ The participant chooses the topic(s) she wants to talk about.

____ The participant and staff member choose the topic(s) together.

____ Other (describe):

19. How often are circle charts or other visual aids used to help participants choose discussion topic(s)? Circle charts display pictures of possible topics relevant to the participant with each circle representing a topic. The nutrition educator asks the participant to choose one topic as the focus of their discussion.

• Circle charts or other visuals are not used

• Rarely

• Occasionally

• Sometimes

• Often

• Almost always

20. For each category of women participants, which seven topics do nutrition educators at the site discuss most often? (Check up to seven topics for each category.)

    Topic	Pregnant	Postpartum	Breastfeeding
    Breastfeeding			
    Calcium intake			
    Cooking/meal preparation			
    Diabetes			
    Dental care			
    Folic acid			
    Food safety/foods to avoid			
    Fruit and vegetables			
    Having enough to eat			
    Healthy snacking			
    High blood pressure/hypertension			
    Infant feeding			
    Iron/anemia			
    Milk (lower fat choices/consumption)			
    Nausea, vomiting, or constipation			
    Physical activity			
    Pica (eating non-food items)			
    Postpartum depression/self-care			
    Postpartum weight loss			
    Prenatal nutrition/diet			
    Preparing for a healthy pregnancy			
    Protein intake			
    Shopping for and preparing healthy foods			
    Sugar-sweetened beverages			
    Vitamin and mineral supplements			
    Water consumption			
    Weight gain during pregnancy			
    Whole grains			
    Other (describe): _______________			

21. Which seven topics do nutrition educators at the site discuss most often with parents/caregivers of infants? (Check up to seven topics.)

• Breastfeeding

• Colic

• Constipation, diarrhea, or vomiting

• Food intolerances/allergies

• Formula preparation/feeding

• Infant feeding practices

• Infant growth and development

• Introduction of cow’s milk

• Introduction of solid foods

• Inappropriate foods (e.g., high-fat foods, fast foods, honey)

• Iron/anemia

• Overfeeding

• Parenting

• Physical activity

• Propping the bottle (leaving infant unattended with bottle)

• Sugar-sweetened beverages

• Water consumption

• Weaning from the bottle

• Other (describe):

22. Which seven topics do nutrition educators at the site discuss most often with parents/caregivers of children? (Check up to seven topics.)

• Child growth and development

• Child feeding practices

• Constipation, diarrhea, or vomiting

• Cooking/meal preparation

• Dental health

• Family meals

• Fruit and vegetables

• Healthy snacks

• Healthy weight for child

• Inappropriate/sometimes foods (e.g., fast foods, high-fat foods)

• Iron/anemia

• Milk (lower fat choices/consumption)

• Parenting

• Physical activity

• Pica (eating non-food items)

• Picky eaters

• Portion sizes

• Screen time

• Shopping for and preparing healthy foods

• Sugar-sweetened beverages

• Water consumption

• Weaning from the bottle

• Whole grains

• Other (describe):

23. During one-on-one counseling sessions at the site, how often are participant behavioral goals (e.g., nutrition or physical activity) set?

• Goal setting is not part of one-on-one counseling sessions

• Rarely

• Occasionally

• Sometimes

• Often

• Almost always

24. How are participant goals selected for most of the one-on-one counseling sessions? (Choose up to three methods and rank them by entering “1” for the method used most often, “2” for the method used next most often, and “3” for the method used next most often.)

____The participant usually identifies the goal(s).

____The staff member usually suggest the goal(s).

____The participant and staff member usually select the goal(s) together.

____Other (describe):

If the site does not provide group education sessions, GO TO QUESTION 28.

25. How often do nutrition educators at the site use the following activities or resources during group education sessions? (Check one response for each activity or resource.)

Activity or Resource	Never	Rarely (<10%)	Occasionally (11–39%)	Some-times (40–59%)	Often (60–89%)	Almost Always (≥90%)
Icebreakers/warm-up activities						
Discussions between pairs of WIC participants						
Educational props (e.g., breastfeeding dolls, food containers)						
Informational charts or displays						
Food sampling/ demonstrations						
Hands-on activity or game						
Physical activity						
PowerPoint presentation						
Video/DVD						

26. How are the topics for group education sessions at the site determined? (Check all that apply.)

• Each day, week, month, or quarter has a specific topic.

• There are specific topics for participant categories (e.g., breastfeeding, class, infant class).

• Participants select from a menu of topics when they schedule their appointments.

• Topics are determined based on participants’ interest during each group session.

• Other (describe):

27. Thinking about the group education sessions at the site over the past 6 months, which seven topics were discussed most often? (Check up to seven topics.)

• Breastfeeding

• Child feeding practices

• Cooking/meal preparation

• Dental health

• Fruit and vegetables

• Healthy snacks

• Healthy weight for child

• Healthy weight for mother

• Infant feeding practices

• Infant/child growth and development

• Introduction of solid foods

• Inappropriate/sometimes foods (e.g., high-fat foods, fast foods)

• Iron/anemia

• Milk (lower fat choices/consumption)

• Parenting

• Physical activity

• Picky eaters

• Portion sizes

• Prenatal nutrition/diet

• Shopping for and preparing healthy foods

• Sugar-sweetened beverages

• Water consumption

• Whole grains

• Weaning from the bottle

• Other (describe):

Questions about You

28. Did you complete the Local Agency Survey for the local agency/program that oversees this site?

• Yes  GO TO QUESTION 34

• No

29. Which job titles or roles do you have? (Check 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):

If you chose only one response for Question 29, GO TO QUESTION 31.

30. Which best describes your primary role in the WIC Program? (Check 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):

31. What is the highest degree you have completed?

• High school diploma or GED

• Associate’s degree

• Bachelor’s degree

• Graduate degree

32. Which, if any, of the following credentials do you have? (Check 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

33. 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

34. As part of your job, do you design and/or oversee nutrition education at the site?

• Yes

• No

35. 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%

36. Please use the space below to share a brief description of any special nutrition education activities or approaches used at the site.

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Thank you for completing the Site Survey for the WIC Nutrition Education Study!