App_S. Administrative data on Lost to Followup Participants

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Overview

Template with sample data
Instructions

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Sheet 1: Template with sample data

Appendix S. Administrative Data on Lost to Followup Participants

Information Provided by Westat

Completed by the State Agency

Extra columns for State Agency's Use if Needed

Caregiver First Name

Caregiver Last Name

Caregiver Date of Birth

Caregiver WIC ID

Child First Name

Child Last Name

Child Date of Birth

Child WIC ID

WIC site at study enrollment

WIC Site State

Last known WIC Clinic

Last Known WIC Clinic State

Phone Number 1

Phone Number 2

Email Address

Address 1

Address 2

City

State

Zip

Reference Period Start Date

Reference Period End Date

Caregiver WIC Benefit Start Date 1

Caregiver WIC Benefit End Date 1

Child WIC Benefit Start Date

Child WIC Benefit End Date

Caregiver WIC Benefit Start Date 2

Caregiver WIC Benefit End Date 2

Child WIC Benefit Start Date 2

Child WIC Benefit End Date 3

Jane

Smith

5/12/1994

AS56789

John

Smith Jr.

8/15/2013

AS87654

Aurora South WIC Clinic

CO

Pueblo

CO

213-555-6678

215-408-9870

Jsmith@gmail.com

123 Main St.

Apt. 2

Pueblo

CO

67543

7/31/2013

8/15/2018

7/31/2013

1/15/2014

9/15/2013

9/15/2014

NA

NA

1/10/2015

8/15/2017

Lisa

Jones

11/5/1987

W546721334

Jane

Jones

5/1/2014

Not Available

Turlock WIC Program

CA

Pearl Nutrition Services

FL

432-555-3454

Not Available

Not Available

876 State St.

Sarasota

FL

19432

9/1/2013

5/1/2019

9/1/2013

9/1/2014

NF

NF

The Food and Nutrition Service (FNS) is collecting this information to investigate (1) the dietary practices and the health and nutritional status of the WIC ITFPS-2 children during the ninth year of life; (2) if participants who left the study were systematically different than those who continued in the study and if these study participants left WIC at the same rate as their counterparts who remained in the study. This is a voluntary collection and FNS will use the information to improve inform WIC service delivery. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0580. The time required to complete this information collection is estimated to average 54.7593. hours (3,285.558 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314. ATTN: PRA (0584-0580). Do not return the completed form to this address.

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Sheet 2: Instructions

Thank you very much for your participation in the WIC Feeding My Baby Study

This spreadsheet includes the list of eligible particpants who left the study before the study child's fifth birthday.

Columns A - T, highlighted in green, include information on the participants from Westat's records to identify the participant in your records.

Columns U and V, highlighted in brown, indicate the start and end dates for the time period of interest.

Columns W - Z are for your use. If the caregiver or the study child (not including any other children in the household) received WIC benefits during the time period of interest, please indicate the date the benefits started and the date the benefits ended using columns W and X for the caregiver and Y and Z for the child.

If there was a break in benefits, use columns AA - AD to indicate when the benefits started and ended after the break. For multiple breaks, please add additional columns

Enter NA in columns W and X if the caregiver did not receive benefits between Reference Period Start Date and Reference Period End Date, and use coloumns Y and Z to indicate the same for the child.

If the caregiver or the child are not found in your records, please enter NF in Columns W and X or Y and Z as applicable

Please contact Bibi Gollapudi at BibiGollapudi@Westat.com or 240-314-7558 in case of any questions.