OMB
Control Number: 0584-XXXX
Expiration date: XX/XX/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 20 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. |
Please fill out and return the survey to the research study staff. Your identity and your answers on the survey will be kept private. We will not share your name and contact information with anyone without your consent. You may skip any questions you do not want to answer. We want to know about you. There are no right or wrong answers.Mark only one x for each question unless it says to mark more than one answer. To change your answer, completely fill the box of the incorrectly marked answer ■. Then mark an x in the correct box.If
you have any questions about this study, please send an e‑mail
to USDA-wic-nest@rti.org
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Different people like different foods. How much do you like …?
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Never
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Don’t
Like |
Like
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Like
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a. Vegetables |
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b. Fruit |
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c. Low-fat (1%) or fat-free/skim milk |
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d. Whole grains such as whole grain bread, whole wheat or corn tortillas, or brown rice |
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The next questions are about the different kinds of foods you ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.
In the past 30 days, how often did you eat hot or cold cereals?
Never GO TO Question 3
Once last month
2–3 times last month
Once a week
Twice a week
3–4 times per week
5–6 times per week
Once a day
More than once a day
2a. In the past 30 days, what kind of cereal did you usually eat? (Print the name of the cereal.)
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2b. If there was another kind of cereal that you usually ate in the past 30 days, what kind was it? (Print the name of the cereal, or if none, leave blank.)
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In the past 30 days, how often did you have any milk (either to drink or on cereal)? Include regular milk, chocolate or flavored milk, lactose-free milk, and buttermilk. Do not include soy milk, almond milk, rice milk, etc. or small amounts of milk added to coffee or tea.
Never GO TO Question 5
Once last month
2–3 times last month
Once a week
Twice a week
3–4 times per week
5–6 times per week
Once a day
More than once a day
In the past 30 days, what kind of milk did you usually drink? (Mark one or more.)
Whole or vitamin D milk
2% or reduced-fat milk
1% or low-fat milk
Fat-free or nonfat/skim milk
Soy milk
Chocolate or flavored milk
Other:__________________________
In the past 30 days, how often did you drink …?
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Never |
Once Last Month |
2–3 Times Last Month |
Once a Week |
Twice a Week |
3–4 Times per Week |
5–6 Times per Week |
Once a Day |
More than Once a Day |
a. Regular soda or pop that contains sugar (Do not include diet soda) |
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b. 100% pure fruit juices with no added sugar, such as orange, mango, apple, grape, and pineapple juices |
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c. Coffee or tea that had sugar or honey added to it such as coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino (Do not include coffee or diet tea with artificial sweeteners such as Equal, Sweet’N Low, or Splenda) |
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d. Sweetened fruit drinks, sports drinks, or energy drinks, such as Kool-Aid, lemonade, HiC, cranberry drink, Gatorade, Red Bull, Vitamin Water, or fruit juices you made at home and added sugar (Do not include diet drinks with artificial sweeteners, such as Equal, Sweet’N Low, or Splenda) |
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In the past 30 days, how often did you eat …?
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Never |
Once Last Month |
2–3 Times Last Month |
Once a Week |
Twice a Week |
3–4 Times per Week |
5–6 Times per Week |
Once a Day |
More than Once a Day |
a. Fruit, including fresh, frozen, dried, or canned fruit (Do not include juices) |
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b. Green leafy or lettuce salad, with or without other vegetables |
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c. Any kind of fried potatoes, including French fries, home fries, or hash brown potatoes |
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d. Any other kind of potatoes, such as baked, boiled, mashed potatoes; sweet potatoes; or potato salad |
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e. Refried beans, baked beans, beans in soup, pork and beans, or any other type of cooked dried beans (Do not include green beans) |
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f. Brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet (Do not include white rice) |
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g. Other vegetables, including fresh, frozen, dried, or canned vegetables (Do not include green salads, potatoes, or cooked dried beans) |
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h. Mexican-type salsa made with tomatoes |
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i. Pizza, including frozen pizza, take-out pizza, pizza in restaurants, and homemade pizza |
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j. Tomato sauce served with spaghetti or noodles or mixed into other foods such as lasagna (Do not include tomato sauce on pizza) |
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k. Any kind of cheese, including cheese as a snack; cheese on burgers and sandwiches; and cheese in foods such as lasagna, quesadillas, or casseroles (Do not include cheese on pizza) |
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l. Corn or whole wheat tortillas (Do not include white flour tortillas) |
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In the past 30 days, how often did you eat …? (continued)
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Never |
Once Last Month |
2–3 Times Last Month |
Once a Week |
Twice a Week |
3–4 Times per Week |
5–6 Times per Week |
Once a Day |
More than Once a Day |
m. Whole grain bread, including whole wheat, rye, oatmeal, and pumpernickel toast and rolls and in sandwiches (Do not include white bread) |
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n. Chocolate or any other types of candy (Do not include sugar-free candy) |
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o. Doughnuts, sweet rolls, Danish, muffins, pan dulce, or Pop-Tarts (Do not include sugar-free kinds) |
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p. Cookies, cake, pie, or brownies (Do not include sugar-free kinds) |
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q. Ice cream or other frozen desserts (Do not include sugar-free kinds) |
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Everyone is different and eats different foods. At this time, are you doing the following things? (Mark one box for each row.)
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NOT thinking about doing it |
Thinking
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Planning on doing it in next month |
Have been doing It for LESS than 6 months |
Have been doing It for 6 months or LONGER |
a. Eat vegetables at dinner every day |
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b. Eat fruit for a snack instead of cookies or chips every day |
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c. Drink low-fat (1%) or fat-free/skim milk instead of whole milk or 2% (reduced fat) milk every day |
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d. Almost always eat whole grain bread instead of white bread |
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e. Almost always eat brown rice instead of white rice |
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f. Almost always eat whole wheat or corn tortillas instead of white flour tortillas |
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g. Drink 100% juice NO MORE than once a day |
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h. Drink regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks NO MORE than once a month. |
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Are you trying to …?
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NOT thinking about doing it |
Thinking about doing it |
Planning on doing it |
Already doing it |
a. Breastfeed my baby until s/he is at least 6 months old |
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b. Breastfeed my baby until s/he is at least 1 year old |
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c. Only breastfeed my baby and NEVER give any formula for the first year of his/her life |
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How sure are you that you can …?
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Not Sure |
A Little Sure |
Very Sure |
a. Eat vegetables at dinner every day |
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b. Eat fruit for a snack instead of cookies or chips every day |
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c. Drink low-fat (1%) or fat-free/skim milk instead of whole milk or 2% (reduced fat) milk every day |
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d. Eat whole grain bread instead of white bread |
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e. Eat brown rice instead of white rice |
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f. Eat whole wheat or corn tortillas instead of white flour tortillas |
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g. Drink 100% juice NO MORE than once a day |
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h. Drink regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks NO MORE than once a month. |
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How sure are you that you can …?
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I Am Not Breastfeeding |
Not Sure |
A Little Sure |
Very Sure |
a. Breastfeed my baby until s/he is at least 6 months old |
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b. Breastfeed my baby until s/he is at least 1 year old |
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c. Only breastfeed my baby and NEVER give any formula for the first year of his/her life |
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Thank you for answering these questions!
Please give your survey to the research study staff.
After your WIC appointment, please return to answer some additional questions.
Please complete Section 2 of the survey now.
How much do you agree or disagree …?
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Disagree
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Disagree
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Agree
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Agree
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a. It is easy to buy fresh fruit and vegetables where I live |
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b. It is expensive to buy fresh fruit and vegetables where I live |
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c. There is a large selection of fresh fruit and vegetables where I live |
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d. The fresh fruit and vegetables where I live are of high quality |
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Was this true for your household in the past 12 months?
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Never True |
Sometimes True |
Often True |
a. We worried whether our food would run out before we got money to buy more |
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b. The food that we bought just didn’t last, and we didn’t have money to get more |
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How often do these things happen?
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Rarely or Never |
Some Days |
Most Days |
Almost Every Day |
Every Day |
a. I eat a meal while watching TV |
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b. I cook a homemade dinner at home |
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Are you currently feeding your baby …?
Only breast milk
Only formula
Both breast milk and formula
Neither breast milk nor formula
When do you feed your baby breast milk or formula?
On a regular schedule
When baby cries or seems hungry
Both of the above
I am not feeding my baby breast milk or formula
How old was your baby when s/he drank formula every day?
At birth or in the hospital
Less than 1 month old
1–2 months old
3–5 months old
6 or more months old
My baby has never had formula every day
How old was your baby when you completely stopped breastfeeding or feeding breast milk from a bottle?
Less than 1 month old
1–2 months old
3–5 months old
6 or more months old
I never fed my baby breast milk
I am still feeding my baby breast milk
How old was your child when you first introduced solid foods by spoon or in a bottle (things like infant cereal or baby food from a jar or homemade)?
Less than 3 months old
4 months old
5 months old
6 months or older
Has not eaten solid foods GO TO Question 20
What was the first solid food that you fed your baby? (Mark one.)
Baby cereal
Vegetables
Fruit
Meat
Other:___________________________________
Have you breastfed any of your other children for 1 month or more?
No, this is my first pregnancy
Yes
No
All people do things differently. Think about what you do in a usual week or day. How many times do you do the following things? (Mark one box for each question.)
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0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 or More |
a. I eat breakfast ___ times a week |
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b. I eat out ___ times a week |
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c. I eat fast food ___ times a week |
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d. I watch TV or DVDs ___ hours a day |
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In the past 7 days, on how many days did you do moderate or vigorous physical activities like walking, jogging, dancing, or bicycling? Think only about physical activities that you did for at least 10 minutes at a time. (Circle one number.)
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
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If you circled 0 GO TO Question 24 |
On the days that you did more than 10 minutes of moderate or vigorous physical activities, how many minutes in a day did you usually spend doing these physical activities?
10–20 minutes
21–30 minutes
31–40 minutes
41–50 minutes
51–60 minutes
More than 60 minutes
In the past 30 days, how often did your family or friends do the following?
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Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
a. Encourage you to eat healthy foods |
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b. Complain about eating healthy foods |
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c. Encourage you to do physical activity |
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d. Do physical activity with you |
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In the past 30 days, how often did you …?
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Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
a. Plan meals ahead of time |
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b. Use Nutrition Facts on food labels to choose foods |
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Add up all the time you or your children have ever been on WIC. Has it been …?
Less than 30 days
1 month to a year
1–2 years
3–4 years
5 or more years
In the past 6 months, how many times did you visit a WIC office and get information on health or healthy eating? Include the day you signed up for this study. Do not include visits for other reasons such as picking up a food instrument or voucher or taking a friend to her appointment. (Mark “Once” if the day you signed up for this study was your first visit to a WIC office.)
None
Once
2 times
3 times
4 times
5 times
6 or more times
In the past 6 months, during WIC visit(s) how many times did you …? Include your most recent visit.
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None |
1 |
2 |
3 |
4 |
5 |
6 or More |
a. Talk one-on-one with a WIC staff person about health or healthy eating |
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b. Attend a group session about health or healthy eating |
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c. Watch a video/DVD about health or healthy eating |
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d. Use the WIC Web site about health or healthy eating |
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In the past 6 months, in between WIC visits, what did you get from WIC with information about health or healthy eating? Do not include things you got during your WIC visit. (Mark all that apply.)
Personal phone call
Text message
Email message
Online education that I could log into from home or someplace else
Invitation or link to Facebook, Twitter, or other social media site
Brochure or handout in the mail
None of the above
The next questions are about your most recent visit to WIC in which you got information on health or healthy eating.
What did you do at your most recent WIC visit? (Mark all that apply)
Talked one-on-one with a WIC staff person about health or healthy eating
Spent time in a group session on health or healthy eating
Used a WIC web site on health or healthy eating
Used a WIC video/DVD on health or healthy eating
None of the above
For your most recent WIC visit, how much do you agree or disagree with each statement …?
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Disagree
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Disagree
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Agree
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Agree
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a. I learned good reasons to eat healthy |
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b. I learned good ways to eat healthy |
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c. I learned good reasons to breastfeed |
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d. I learned good ways to breastfeed |
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e. I learned good reasons to introduce solid foods to my baby |
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f. I learned good ways to introduce solid foods to my baby |
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Some people say that some WIC visits are more helpful than others. Which best describes the information you received at your most recent WIC visit? (Mark one box only.)
The information was helpful because it was new to me.
The information was helpful. I knew the information, but it was good to hear it again.
The information was not that helpful because I already knew it.
The information was not that helpful because it did not apply to me.
Which best describes your most recent WIC visit? (Mark one box only.)
I did not have any children with me
I had a child with me so it made it hard to listen to the WIC information
I had a child with me but it was easy to listen to the WIC information
At your most recent WIC visit, did the WIC staff show you any of the following or use any of these with you while they talked about health or healthy eating? (Mark all that apply.)
Brochure, handout, or paper with information
Bulletin board or poster
Video/DVD
Tasting or cooking demonstration
Activity or game
Other items that you could pass around like measuring cups, food containers, etc.
None of the above
Other: ________________________________________________
When you enroll in WIC and then 6 to 12 months later, WIC asks you to bring proof of address or income to make sure you can be on WIC. Did you bring proof to your most recent WIC visit?
Yes
No
At your most recent WIC visit, how long did you talk one-on-one with a WIC staff person about health or healthy eating?
I did not talk one-on-one about health or healthy eating GO TO Question 42
Less than 5 minutes
5–15 minutes
16–30 minutes
More than 30 minutes
Answer Questions 37 to 41 only if you had one-on-one time with WIC staff at your most recent WIC visit. (If you did not have one-on-one time, go to Question 42.)
Which best describes your most recent one-on-one time with a WIC staff person? (Mark the one that happened most.)
The WIC staff person chose what we talked about
I chose what we talked about
The WIC staff person and I together chose what we talked about
A health goal means trying to become healthier by changing something you do. Which best describes your most recent one-on-one time with a WIC staff person? (Mark the one that happened most.)
S/he worked with me to set health goals for me or my child
S/he talked about health goals, but I did not set any
S/he did not talk about setting health goals
For each statement, how much do you agree or disagree about your most recent one-on-one time with a WIC staff person?
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Disagree
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Disagree
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Agree
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Agree
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a. The WIC staff person talked most of the time |
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b. The WIC staff person listened to me and understood my concerns |
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c. The WIC staff person followed up on issues or questions from my last one-on-one visit |
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We talked about this |
We did NOT talk about this |
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I am NOT thinking about doing it |
I am thinking about doing it |
I am planning on doing it |
I am already doing it |
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a. Eating more fruit and vegetables |
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b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
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c. Drinking lower fat milk (1% or fat-free/skim milk) |
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d. Getting more physical activity |
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e. Shopping for and preparing healthier foods |
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f. Drinking water instead of soda and sugary drinks |
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g. Breastfeeding |
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h. Introducing solid foods to my baby |
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At your most recent WIC visit, how long did you spend in a group session talking about health or healthy eating?
I was not in a group session GO TO Question 48
Less than 5 minutes
5–15 minutes
16–30 minutes
More than 30 minutes
Answer Questions 43 to 47 only if you spent time in a group session at your most recent WIC visit. (If you were not in a group session, go to Question 48.)
Which best describes your most recent WIC group session? (Mark the one that happened most.)
S/he mostly talked and would stop to ask if we had questions
We watched a video/DVD and at the end s/he asked if we had questions
S/he shared information and we had a discussion. S/he asked me and the other people in the group about our thoughts and opinions.
A health goal means trying to become healthier by changing something you do. Which best describes your group session with a WIC staff person? (Mark the one that happened most.)
S/he worked with me to set health goals for me or my child
S/he talked about health goals, but I didn’t set any
S/he did not talk about setting health goals
For each statement, how much do you agree or disagree about your most recent WIC group session?
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Disagree
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Disagree
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Agree
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Agree
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a. The WIC staff person listened to the group and understood our concerns |
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b. I had a chance to bring up topics that were important to me |
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We talked about this |
We did NOT talk about this |
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I am NOT thinking about doing it |
I am thinking about doing it |
I am planning on doing it |
I am already doing it |
a. Eating more fruit and vegetables |
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b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
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c. Drinking lower fat milk (1% or fat-free/skim milk) |
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d. Getting more physical activity |
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e. Shopping for and preparing healthier foods |
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f. Drinking water instead of soda and sugary drinks |
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g. Breastfeeding |
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h. Introducing solid foods to my baby |
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Which describes how you used a WIC Web site on health or healthy eating in the past 6 months? (Mark all that apply.)
Used a WIC Web site on health or healthy eating in the WIC office by myself
Used a WIC Web site on health or healthy eating instead of going to a WIC appointment
Used a WIC Web site on health or healthy eating before or after going to a WIC appointment
Have not used a WIC Web site on health or healthy eating in the past 6 months GO TO Question 53
Answer Question 49 to 52 only if you used a WIC Web site on health or healthy eating in the past 6 months. (If you did not use a WIC Web site, go to Question 53.)
How long did you spend using the WIC Web site? Include time in and outside of WIC office.
Less than 5 minutes
5–15 minutes
15–30 minutes
More than 30 minutes
Which best describes how the topic for the WIC Web site was chosen? (Mark one.)
There was a list of topics, and I chose one of them myself
There was a list of topics, and a WIC staff person helped me choose one
There was only one topic available
Other: ____________________________
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I read/ viewed this |
I did NOT read/ view this |
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I am NOT thinking about doing it |
I am thinking about doing it |
I am planning on doing it |
I am already doing it |
a. Eating more fruit and vegetables |
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b. Eating more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice |
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c. Drinking lower fat milk (1% or fat-free/skim milk) |
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d. Getting more physical activity |
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e. Shopping for and preparing healthier foods |
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f. Drinking water instead of soda and sugary drinks |
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g. Breastfeeding |
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h. Introducing solid foods to my baby |
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Which describes how you used a WIC video/DVD on health or healthy eating in the past 6 months? (Mark all that apply.)
Used a WIC video/DVD on health or healthy eating in the WIC office by myself
Used a WIC video/DVD on health or healthy eating in the WIC office in a group
Used a WIC video/DVD on health or healthy eating instead of going to a WIC appointment
Used a WIC video/DVD on health or healthy eating before or after going to a WIC appointment
Have not used a WIC video/DVD on health or healthy eating in the past 6 months
Which best describes your current status? Are you …? (Mark the best answer.)
Married
Widowed
Divorced
Separated
Single or never married
Living with partner
Are you Hispanic or Latino? (Mark one.)
Hispanic or Latino
Not Hispanic or Latino
What is your race? (Mark one or more.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other; Specify:________________________________
What is the highest year or grade you finished in school? (Mark one.)
Less than 1 year of school
Elementary (grades 1–8)
Some high school (grades 9–12, no degree)
High school graduate, GED, or equivalent
Some college (1–4 years, no degree)
Associate’s degree (including occupational or academic degrees)
Bachelor’s degree (BA, BS, AB, etc.)
Master’s degree or higher (MA, MS, PhD, MD, etc.)
In the past 6 months, have you been told by a doctor or other health care professional that you have …?
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Yes |
No |
a. Anemia or low iron |
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b. Excessive weight gain |
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c. Diabetes, gestational diabetes, or high blood sugar |
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d. High blood pressure |
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Are you currently working for pay either full time or part time?
Yes, full time
Yes, part time
No
What language(s) do you speak at home? (Mark all that apply.)
English
Spanish
Other
How many people live in your household right now?
|
Number |
a. Infants under 12 months of age |
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b. Children 1–4 years of age |
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c. Children 5–17 years of age |
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d. Adults 18 years or older (include yourself) |
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How many people in your household are on WIC right now? Please include yourself. _____
Do you have regular childcare for your youngest child where someone other than you or your child’s other parent takes care of him/her on a regular basis?
Yes How many hours per week is your child usually in childcare? _____
No
Which do you receive now? (Mark all that apply.)
Supplemental Nutrition Assistance Program benefits, sometimes called SNAP or Food Stamps
Temporary Assistance to Needy Families, sometimes called TANF or welfare
Medicaid or ______________[INSERT STATE-SPECIFIC NAME FOR MEDICAID]
Head Start
Food from food bank, food pantry or soup kitchen
Other food assistance program; Specify:________________________________
I do not receive any assistance besides WIC
Which have you ever received but DON’T receive now? (Mark all that apply.)
Supplemental Nutrition Assistance Program benefits, sometimes called SNAP or Food Stamps
Temporary Assistance to Needy Families, sometimes called TANF or welfare
Medicaid or ________________ [INSERT STATE-SPECIFIC NAME FOR MEDICAID]
Head Start
Food from food bank, food pantry or soup kitchen
Other food assistance program; Specify:________________________________
I have not received any assistance besides WIC
|
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a. Breastfeeding |
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b. Weaning from a bottle |
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c. Drinking milk/choosing lower fat milk |
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d. Drinking water |
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e. Fruit and vegetables |
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f. Healthy snacking |
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g. Healthy weight for myself |
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h. Introducing solid foods to my baby |
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i. Medical conditions such as low iron or high blood sugar |
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j. Physical activity |
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k. Picky eaters |
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l. Shopping for and preparing healthy foods |
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m. Sodas and sugary drinks |
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n. Whole grains |
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o. None of the above |
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Thank you for filling out the survey!
You will get another survey in several months.
Thank you for taking part in the WIC Nutrition Education Study (NEST)!
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | APPENDIX K: |
Author | scc |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |