OMB
Control Number: 0584-XXXX
Expiration date: XX/XX/XXXX
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|
|
(month) |
(day) |
(year) |
Different people like different foods. How much do you like…? [READ ITEMS.] Would you say you…? SELECT ONE.
a. Vegetables |
Have
Never |
Don’t
Like It |
Like
It |
Like
It |
-4 DON’T KNOW |
-7 REFUSAL |
b. Fruit |
Have
Never |
Don’t
Like It |
Like
It |
Like
It |
-4 DON’T KNOW |
-7 REFUSAL |
c. Low-fat, 1%, fat-free, or skim milk |
Have
Never |
Don’t
Like It |
Like
It |
Like
It |
-4 DON’T KNOW |
-7 REFUSAL |
d. Whole grains, such as whole grain bread, whole wheat or corn tortillas, or brown rice |
Have
Never |
Don’t
Like It |
Like
It |
Like
It |
-4 DON’T KNOW |
-7 REFUSAL |
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? Would you say…? SELECT ONE.
Never [Go to Question 4]
Once last month
2 to 3 times last month
Once a week
Twice a week
3 to 4 times per week
5 to 6 times per week
Once a day
More than once a day
-4 DON’T KNOW
-7 REFUSAL
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.
3a. In the past 30 days, what kind of cereal did you usually eat? ENTER NAME OF CEREAL.
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3b. If there was another kind of cereal that you ate in the past 30 days, what kind was it? ENTER NAME OF CEREAL, OR IF NONE, ENTER 1.
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In the past 30 days, how often did you have any milk either to drink or on cereal? Please 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. Would you say you…? SELECT ONE.
Never [Go to Question 6]
Once last month
2 to 3 times last month
Once a week
Twice a week
3 to 4 times per week
5 to 6 times per week
Once a day
More than once a day
-4 DON’T KNOW
-7 REFUSAL
In the past 30 days, what kind of milk did you usually drink? Would you say…? SELECT ALL THAT APPLY.
Whole or vitamin D milk
2% milk, which is also called reduced-fat milk
1% milk, which is also called low-fat milk
Skim milk, which is also called fat-free or nonfat milk
Soy milk
Chocolate or flavored milk
Another kind of milk. [If selected] What kind of milk did you drink? ENTER RESPONSE. ____________________________
-4 DON’T KNOW
-7 REFUSAL
In the past 30 days, how often did you drink…? [READ ITEMS.] Would you say…? SELECT ONE FOR EACH ITEM.
a. Regular soda or pop that contains sugar. Do not include diet soda. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
b. 100% pure fruit juices with no added sugar, such as orange, mango, apple, grape, and pineapple juices |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
c. Coffee or tea that had sugar or honey added to it, such as coffee and tea you sweetened yourself, or 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. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
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 that you made at home and added sugar. Do not include diet drinks with artificial sweeteners, such as Equal, Sweet’N Low, or Splenda. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
In the past 30 days, how often did you eat…? [READ ITEMS.] Would you say…? REPEAT AFTER EVERY THREE FOODS. SELECT ONE FOR EACH ITEM.
a. Fruit, including fresh, frozen, dried, or canned fruit. Do not include juices. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
b. Green leafy or lettuce salad, with or without other vegetables |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
c. Any kind of fried potatoes, including French fries, home fries, or hash brown potatoes |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
d. Any other kind of potatoes, such as baked, boiled, mashed potatoes; sweet potatoes; or potato salad |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
e. Refried beans, baked beans, beans in soup, pork and beans, or any other type of cooked dried beans. Do not include green beans. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
f. Brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet. Do not include white rice. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
g. Other vegetables, including fresh, frozen, dried, or canned vegetables. Do not include green salads, potatoes, or cooked dried beans. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
h. Mexican-type salsa made with tomatoes |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
i. Pizza, including frozen pizza, take-out pizza, pizza in restaurants, and homemade pizza |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
j. Tomato sauce served with spaghetti or noodles or mixed into other foods such as lasagna. Do not include tomato sauce on pizza. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
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. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
l. Corn or whole wheat tortillas. Do not include white flour tortillas. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
m. Whole grain bread, including whole wheat, rye, oatmeal, and pumpernickel toast and rolls and in sandwiches. Do not include white bread. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
n. Chocolate or any other types of candy. Do not include sugar-free candy. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
o. Doughnuts, sweet rolls, Danish, muffins, pan dulce, or Pop-Tarts. Do not include sugar-free kinds. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
p. Cookies, cake, pie, or brownies. Do not include sugar-free kinds. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
q. Ice cream or other frozen desserts. Do not include sugar-free kinds. |
Never |
Once Last Month |
2 to 3 Times Last Month |
Once a Week |
Twice a Week |
3 to 4 Times per Week |
5 to 6 Times per Week |
Once a Day |
More than Once a Day |
-4 DON’T KNOW |
-7 REFUSAL |
Everyone
is different and eats different foods. For the next question, I’m
going to list several activities. For each activity, please tell me
if at this time you are not thinking about doing it; thinking
about doing it; planning to do it next month; have been doing it for
less than 6 months; or have been doing it for 6 months or longer.
The first/next activity is… [READ ITEMS.] Would
you say you…? REPEAT AFTER EVERY THREE STATEMENTS. SELECT ONE
FOR EACH STATEMENT.
a. Eat vegetables at dinner every day |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eat fruit for a snack instead of cookies or chips every day |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drink low-fat, 1%, fat-free, or skim milk instead of whole milk, 2%, or reduced fat milk every day |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
d. Almost always eat whole grain bread instead of white bread |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
e. Almost always eat brown rice instead of white rice |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
f. Almost always eat whole wheat or corn tortillas instead of white flour tortillas |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
g. Drink 100% juice no more than once a day |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
h. Drink regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks no more than once a month |
Are Not Thinking about Doing It |
Are Thinking about Doing It |
Are Planning to Do It Next Month |
Have Been Doing It for Less Than 6 Months |
Have Been Doing It for 6 Months or Longer |
-4 DON’T KNOW |
-7 REFUSAL |
Again, I’m going to read you a list of activities. For each activity, please tell me how sure you are you could do the activity. How sure are you that you can…? [READ ITEMS.] Would you say you are…? SELECT ONE FOR EACH STATEMENT.
a. Only formula feed your baby, not breastfeed at all |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
b. Breastfeed your baby or at least try |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
c. Breastfeed without using any formula or other milk your baby is 30 days old |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
d. Breastfeed without using any formula or other milk your baby is 6 months old |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
I’m going to read you a list of activities. For each activity, please tell me how sure you are you could do the activity. How sure are you that you can…? [READ ITEMS.] Would you say you are…? REPEAT AFTER EVERY 3 STATEMENTS.SELECT ONE FOR EACH STATEMENT.
a. Eat vegetables at dinner every day |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eat fruit for a snack instead of cookies or chips every day |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drink low-fat, 1%, fat-free, or skim milk instead of whole milk, 2%, or reduced fat milk every day |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
d. Eat whole grain bread instead of white bread |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
e. Eat brown rice instead of white rice |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
f. Eat whole wheat or corn tortillas instead of white flour tortillas |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
g. Drink 100% juice no more than once a day |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
h. Drink regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks no more than once a month |
Not Sure |
A Little Sure |
Very Sure |
-4 DON’T KNOW |
-7 REFUSAL |
For the next question, I’m going to read you four statements. Please tell me how much do you agree or disagree with the statement. [READ ITEMS.] Would you say you…? SELECT ONE FOR EACH STATEMENT.
a. It is easy to buy fresh fruit and vegetables where I live |
Disagree
|
Disagree |
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
b. It is expensive to buy fresh fruit and vegetables where I live |
Disagree
|
Disagree |
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
c. There is a large selection of fresh fruit and vegetables where I live |
Disagree
|
Disagree |
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
d. The fresh fruit and vegetables where I live are of high quality |
Disagree
|
Disagree |
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
For the next question, I’m going to list some WIC foods. Please tell me whether you bought the WIC food in the past 30 days. If you did not receive the food from WIC, please let me know. In the past 30 days, did you buy…? [READ ITEMS.] SELECT ONE FOR EACH STATEMENT.
a. Juice |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
b. Fruit and vegetables |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
c. Milk |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
d. Cereal |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
e. Other whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
f. Baby food in jars |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
g. Infant formula |
YES |
NO |
DID NOT RECEIVE FROM WIC |
-4 DON’T KNOW |
-7 REFUSAL |
For the next question, I’m going to read you two statements. Please tell me if this statement was true for your household in the past 12 months. [READ ITEMS.] Would you say this was…? SELECT ONE FOR EACH STATEMENT.
a. We worried whether our food would run out before we got money to buy more |
Never True |
Sometimes True |
Often True |
-4 DON’T KNOW |
-7 REFUSAL |
b. The food that we bought just didn’t last, and we didn’t have money to get more |
Never True |
Sometimes True |
Often True |
-4 DON’T KNOW |
-7 REFUSAL |
I’m going to list two activities. For each activity, please tell me how often you do the activity. How often do you…? [READ ITEMS.] Would you say…? SELECT ONE FOR EACH STATEMENT.
a. Eat a meal while watching TV |
Rarely or Never |
Some Days |
Most Days |
Almost Every Day |
Every Day |
-4 DON’T KNOW |
-7 REFUSAL |
b. Cook a homemade dinner at home |
Rarely or Never |
Some Days |
Most Days |
Almost Every Day |
Every Day |
-4 DON’T KNOW |
-7 REFUSAL |
All people do things differently. For each activity, please tell me how many times you do the activity in a usual week or day. [READ ITEMS.] SELECT ONE FOR EACH ACTIVITY.
a. How many times a week do you eat breakfast? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
|
-4 DON’T KNOW |
-7 REFUSAL |
b. How many times a week do you eat out? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
c. How many times a week do you eat fast food? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
d. How many hours a day do you watch TV or DVDs? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
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. SELECT ONE.
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
-4 DON’T KNOW |
-7 REFUSAL |
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|
|
|
|
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[If 0, go to Question 18] |
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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? Would you say…? SELECT ONE.
10 to 20 minutes
21 to 30 minutes
31 to 40 minutes
41 to 50 minutes
51 to 60 minutes
More than 60 minutes
-4 DON’T KNOW
-7 REFUSAL
In the past 30 days, how often did your family or friends…? [READ ITEMS.] Would you say they did it…? SELECT ONE FOR EACH STATEMENT.
a. Encourage you to eat healthy foods |
Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
-4 DON’T KNOW |
-7 REFUSAL |
b. Complain about eating healthy foods |
Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
-4 DON’T KNOW |
-7 REFUSAL |
c. Encourage you to do physical activity |
Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
-4 DON’T KNOW |
-7 REFUSAL |
d. Do physical activity with you |
Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
-4 DON’T KNOW |
-7 REFUSAL |
In the past 30 days, how often did you…? [READ ITEMS.] Would you say…? SELECT ONE.
a. Plan meals ahead of time |
Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
-4 DON’T KNOW |
-7 REFUSAL |
b. Use Nutrition Facts on food labels to choose foods |
Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
-4 DON’T KNOW |
-7 REFUSAL |
Who in your family currently gets WIC benefits? Would you say…? SELECT ALL THAT APPLY.
You, because you are pregnant
You, because you recently gave birth
Your baby who is less than 12 months old
Your child or children who are over 12 months of age
No one in your family [Go to Question 22]
-4 DON’T KNOW
-7 REFUSAL
Do your WIC benefits come from the [Insert name] WIC office? Would you say…? SELECT ONE.
Yes [Go to Question 22]
No, you are receiving WIC from another WIC office [Go to Question 22]
No, you are not currently receiving WIC
-4 DON’T KNOW
-7 REFUSAL
|
|
(month) |
(year) |
In the past 6 months, how many times did you visit a WIC office and get information on health or healthy eating? Do not include visits for other reasons, such as picking up a food instrument or voucher or taking a friend to her appointment. SELECT ONE.
NONE [Go to Question 50]
ONCE
2 TIMES
3 TIMES
4 TIMES
5 TIMES
6 OR MORE TIMES
-4 DON’T KNOW
-7 REFUSAL
For the next question, please include your most recent visit to WIC. In the past 6 months, during WIC visits, how many times did you…? [READ ITEMS.] SELECT ONE FOR EACH STATEMENT.
a. Talk one-on-one with a WIC staff person about health or healthy eating |
NONE |
1 |
2 |
3 |
4 |
5 |
6 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
b. Attend a group session about health or healthy eating |
NONE |
1 |
2 |
3 |
4 |
5 |
6 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
c. Watch a video or DVD about health or healthy eating |
NONE |
1 |
2 |
3 |
4 |
5 |
6 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
d. Use the WIC Web site about health or healthy eating |
NONE |
1 |
2 |
3 |
4 |
5 |
6 OR MORE |
-4 DON’T KNOW |
-7 REFUSAL |
In the past 6 months, in between WIC visits, did you get any of the following from WIC with information that told you about health or healthy eating? Do not include things you got during your WIC visit. SELECT 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
-4 DON’T KNOW
-7 REFUSAL
The next questions are about your most recent visit to WIC in which you got information on health or healthy eating.
When was your most recent WIC visit? SELECT ONE.
Less than 2 weeks ago
2 to 4 weeks ago
1 to 2 months ago
Over 2 months ago
-4 DON’T KNOW
-7 REFUSAL
What did you do at your most recent WIC visit? Did you…? SELECT ALL THAT APPLY.
Talk one-on-one with a WIC staff person about health or healthy eating
Spend time in a group session on health or healthy eating
Use a WIC Web site on health or healthy eating
Use a WIC video or DVD on health or healthy eating
NONE OF THE ABOVE
-4 DON’T KNOW
-7 REFUSAL
For the next question, I’m going to read you several statements. For your most recent WIC visit, how much do you agree or disagree with the statement? [READ ITEMS.] Would you say you…? SELECT ONE FOR EACH STATEMENT.
a. I learned good reasons to eat healthy |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
b. I learned good ways to eat healthy |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
c. I learned good reasons to breastfeed |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
d. I learned good ways to breastfeed |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
Some people say that some WIC visits are more helpful than others. Which of the following statements best describes the information you received at your most recent WIC visit? SELECT ONE.
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.
-4 DON’T KNOW
-7 REFUSAL
Which of the following statements best describes your most recent WIC visit? SELECT ONE.
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
-4 DON’T KNOW
-7 REFUSAL
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? SELECT 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 or food containers
NONE OF THE ABOVE
Something else. [If selected] What did she or he show you? ENTER RESPONSE. ________________________________________________
-4 DON’T KNOW
-7 REFUSAL
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? SELECT ONE.
YES
NO
-4 DON’T KNOW
-7 REFUSAL
At your most recent WIC visit, how long did you talk one-on-one with a WIC staff person about health or healthy eating? Would you say…? SELECT ONE.
I did not talk one-on-one about health or healthy eating [Go to Question 38]
Less than 5 minutes
5 to 15 minutes
16 to 30 minutes
More than 30 minutes
-4 DON’T KNOW
-7 REFUSAL
For the next set of questions, please think about your most recent one-on-one time with a WIC staff person.
Which of the following statements best describes your most recent one-on-one time with a WIC staff person? SELECT ONE.
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
-4 DON’T KNOW
-7 REFUSAL
A health goal means trying to become healthier by changing something you do. Which of the following statements best describes your most recent one-on-one time with a WIC staff person? SELECT ONE.
She worked with me to set health goals for me or my child
She talked about health goals, but I did not set any
She did not talk about setting health goals
-4 DON’T KNOW
-7 REFUSAL
For the next question, I’m going to read you three statements. For your most recent one-on-one time with a WIC staff person, how much do you agree or disagree with the statement? [READ STATEMENTS.] Would you say you…? SELECT ONE FOR EACH STATEMENT.
a. The WIC staff person talked most of the time |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
b. The WIC staff person listened to me and understood my concerns |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
c. The WIC staff person followed up on issues or questions from my last one-on-one visit |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
Please tell me if you talked about any of the following topics in your most recent one-on-one time with a WIC staff person. Did you talk about…? [READ STATEMENTS.] SELECT ONE FOR EACH STATEMENT.
a. Eating more fruit and vegetables |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drinking lower fat milk; that is, 1%, fat-free, or skim milk |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
d. Getting more physical activity |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
e. Shopping for and preparing healthier foods |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
f. Drinking water instead of soda and sugary drinks |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
g. Breastfeeding |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
[If yes to any topics] Now I would like to know if you have made or think you will make a change to your eating or activities since discussing the topic, [READ TOPIC]. Would you say you are…? SELECT ONE FOR EACH STATEMENT.
a. Eating more fruit and vegetables |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drinking lower fat milk; that is, 1%, fat-free, or skim milk |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
d. Getting more physical activity |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
e. Shopping for and preparing healthier foods |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
f. Drinking water instead of soda and sugary drinks |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
g. Breastfeeding |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
At your most recent WIC visit, how long did you spend in a group session talking about health or healthy eating? Would you say…? SELECT ONE.
I was not in a group session [Go to Question 44]
Less than 5 minutes
5 to 15 minutes
16 to 30 minutes
More than 30 minutes
-4 DON’T KNOW
-7 REFUSAL
For the next set of questions, please think about your most recent WIC group session.
Which of the following statements best describes your most recent WIC group session? SELECT ONE.
She mostly talked and would stop to ask if we had questions
We watched a video or DVD, and at the end, she asked if we had questions
She shared information, and we had a discussion. She asked me and the other people in the group about our thoughts and opinions.
-4 DON’T KNOW
-7 REFUSAL
A health goal means trying to become healthier by changing something you do. Which of the following statements best describes your most recent group session with a WIC staff person? SELECT ONE.
She worked with me to set health goals for me or my child
She talked about health goals, but I didn’t set any
She did not talk about setting health goals
-4 DON’T KNOW
-7 REFUSAL
For the next question, I’m going to read you two statements. For your most recent WIC group session, how much do you agree or disagree with the statement? [READ STATEMENTS.] Would you say you…? SELECT ONE FOR EACH STATEMENT.
a. The WIC staff person listened to the group and understood our concerns |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
b. I had a chance to bring up topics that were important to me |
Disagree
|
Disagree
|
Agree
|
Agree
|
-4 DON’T KNOW |
-7 REFUSAL |
Please tell me if you talked about any of the following topics in your most recent WIC group session. Did you talk about…? [READ STATEMENTS.] SELECT ONE FOR EACH STATEMENT.
a. Eating more fruit and vegetables |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drinking lower fat milk; that is, 1%, fat-free, or skim milk |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
d. Getting more physical activity |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
e. Shopping for and preparing healthier foods |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
f. Drinking water instead of soda and sugary drinks |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
g. Breastfeeding |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
[If yes to any topics] Now I would like to know if you have made or think you will make a change to your eating or activities since discussing the topic, [READ TOPIC]. Would you say you are…? SELECT ONE FOR EACH STATEMENT
a. Eating more fruit and vegetables |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drinking lower fat milk; that is, 1%, fat-free, or skim milk |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
d. Getting more physical activity |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
e. Shopping for and preparing healthier foods |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
f. Drinking water instead of soda and sugary drinks |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
g. Breastfeeding |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
Which of the following statements describes how you used a WIC Web site on health or healthy eating in the past 6 months? SELECT ALL THAT APPLY.
I used a WIC Web site on health or healthy eating in the WIC office by myself
I used a WIC Web site on health or healthy eating instead of going to a WIC appointment
I used a WIC Web site on health or healthy eating before or after going to a WIC appointment
I have not used a WIC Web site on health or healthy eating in the past 6 months [Go to Question 49]
-4 DON’T KNOW
-7 REFUSAL
For the next set of questions, please think about the last time you used a WIC Web site on health or healthy eating in the past 6 months.
How long did you spend using the WIC Web site? Please include time in and outside of WIC office. SELECT ONE.
Less than 5 minutes
5 to 15 minutes
15 to 30 minutes
More than 30 minutes
-4 DON’T KNOW
-7 REFUSAL
Which of the following statements best describes how the topic for the WIC Web site was chosen? SELECT 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
The topic was chosen another way. [If selected] How was the topic for the WIC Web site chosen? ENTER RESPONSE. ____________________________
-4 DON’T KNOW
-7 REFUSAL
Please tell me if you read or viewed any of the following topics on the WIC Web site. Did you read or view anything about…? [READ STATEMENTS.] SELECT ONE FOR EACH STATEMENT.
a. Eating more fruit and vegetables |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drinking lower fat milk; that is, 1%, fat-free, or skim milk |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
d. Getting more physical activity |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
e. Shopping for and preparing healthier foods |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
f. Drinking water instead of soda and sugary drinks |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
g. Breastfeeding |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
[If yes to any topics] Now I would like to know if you have made or think you will make a change to your eating or activities since reading or viewing the topic, [READ TOPIC]. Would you say you are…? SELECT ONE FOR EACH STATEMENT.
a. Eating more fruit and vegetables |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
b. Eating more whole grains, like whole grain bread, whole wheat or corn tortillas, or brown rice |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
c. Drinking lower fat milk; that is, 1%, fat-free, or skim milk |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
d. Getting more physical activity |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
e. Shopping for and preparing healthier foods |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
f. Drinking water instead of soda and sugary drinks |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
g. Breastfeeding |
Not Thinking about Doing It |
Thinking about Doing It |
Planning on Doing It |
Already Doing It |
-4 DON’T KNOW |
-7 REFUSAL |
Which statements describe how you used a WIC video/DVD on health or healthy eating in the past 6 months? SELECT ALL THAT APPLY.
I used a WIC video or DVD on health or healthy eating in the WIC office by myself
I used a WIC video or DVD on health or healthy eating in the WIC office in a group
I used a WIC video or DVD on health or healthy eating instead of going to a WIC appointment
I used a WIC video or DVD on health or healthy eating before or after going to a WIC appointment
I have not used a WIC video or DVD on health or healthy eating in the past 6 months
-4 DON’T KNOW
-7 REFUSAL
Which best describes your current status? Are you…? SELECT ONE.
Married
Widowed
Divorced
Separated
Single or never married
Living with partner
-4 DON’T KNOW
-7 REFUSAL
Are you currently pregnant? SELECT ONE.
|
|
|
(month) |
(day) |
(year) |
|
|
(month) |
(year) |
NO, I LOST THE BABY OR ENDED THE PREGNANCY
In the past 6 months, have you been told by a doctor or other health care professional that you have…? SELECT ONE FOR EACH ITEM.
a. Anemia or low iron |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
b. Excessive weight gain |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
c. Diabetes, gestational diabetes, or high blood sugar |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
d. High blood pressure |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
Are you currently working for pay either full time or part time? SELECT ONE.
YES, FULL TIME
YES, PART TIME
NO
-4 DON’T KNOW
-7 REFUSAL
Think about the number of people who live in your household right now. How many people are there in each of the following age group?
|
ENTER NUMBER. IF NONE, ENTER ZERO |
a. Infants under 12 months of age |
|
b. Children 1 to 4 years of age |
|
c. Children 5 to 17 years of age |
|
d. Adults 18 years or older, including yourself |
|
How many people in your household are on WIC right now? Please include yourself. ENTER NUMBER _____
Do you have regular childcare for your youngest child where someone other than you or your child’s other parent takes care of him or her on a regular basis? SELECT ONE.
CHILD HAS NOT BEEN BORN YET [Go to Question 57]
YES
NO [Go to Question 57]
-4 DON’T KNOW
-7 REFUSAL
56a. How many hours per week is your child usually in childcare? ENTER NUMBER _____
Which of the following do you receive now? SELECT 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
-4 DON’T KNOW
-7 REFUSAL
|
|
|
||||
DOES NOT APPLY. HAS NOT BEEN IN WIC IN THE PAST 6 MONTHS [Go to Question 60] |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
a. Breastfeeding |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
b. Weaning from a bottle |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
c. Drinking milk or choosing lower fat milk |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
d. Drinking water |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
e. Fruit and vegetables |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
f. Healthy snacking |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
g. Healthy weight for myself |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
h. Introducing solid foods to my baby |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
i. Medical conditions such as low iron or high blood sugar |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
j. Physical activity |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
k. Picky eaters |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
l. Shopping for and preparing healthy foods |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
m. Sodas and sugary drinks |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
n. Whole grains |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
o. NONE OF THE ABOVE |
YES |
NO |
-4 DON’T KNOW |
-7 REFUSAL |
|
|
What activities or changes would make WIC nutrition education more useful and helpful to you?
You have completed the last survey.
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 |