1. What is your household’s monthly income before taxes (do not include food stamps)? (please check one)

(p.21, #11)

____ 0-$500 ____ $1500 – 2000

____ $500 – 1000 ____ $2000 or more

____ $1000 – 1500 ____ Don’t know

2. How many adults and children are living in your household at this time? (p.54, #1)

Adults (include yourself) ____

Children ____

3. Do you have health insurance for your children? r yes r no

On a scale of 1 to 3, how well do you think you are doing with each of the following work activities (circle a number for each)

Need Average Above

1. Personalize services for participants 1 2 3
2. Link participants with resources/referrals 1 2 3
3. Use effective follow-up procedures 1 2 3
4. Develop/maintain community resources 1 2 3
5. Identify participant barriers 1 2 3
6. Learn and teach self-esteem building skills 1 2 3
7. Motivate and empower participants 1 2 3
8. Provide breastfeeding information and support 1 2 3
9. Talk with participants about weight management 1 2 3
10. Answer participants’ questions about parenting 1 2 3
11. Promote physical activity 1 2 3
12. Understand different cultures 1 2 3
13. Participate in community coalitions 1 2 3

1. If a person is fat, what do you think are the reasons? (P. 114, # 34)

A. They don’t exercise enough …………………… ÿ ÿ

B. They have big bones …………………………… ÿ ÿ

C. They have a gland problem or something is

wrong with their body …………………………. ÿ ÿ

D. They eat the wrong foods ……………………… ÿ ÿ

E. They don’t control themselves ………………… ÿ ÿ

F. They eat a lot of snacks ………………………… ÿ ÿ

G. They eat a lot …………………………………… ÿ ÿ

H. It is natural for them to be fat ………………….. ÿ ÿ

1. How old should a child be when WIC begins teaching the mother about promoting healthy body weight? (suggested by VA)
2. What would you want included in a healthy weight/obesity prevention guide? Would you use this type of implementation guide? (suggested by VA)
3. How concerned do you think parents are about their children being or becoming obese?

How high of a priority is weight maintenance/nutrition for WIC parents?

Is "bigger" sometimes considered better?

4. What are some food, eating, or mealtime behaviors in children that you often hear parents complaining about? (P. 34, #1)
5. What are some ways that parents try to encourage or limit their child's eating? (P. 34, #2)

1. How comfortable are you at the WIC clinic? (p.10, #5)

• Very comfortable
• Somewhat comfortable

1. What would you like to learn about at WIC (check no more than 5)? (p.12, #5)

____ Good Nutrition ____ Iron Rich Foods ____ Planning meals

____ Breastfeeding ____ Physical Activities for kids

____ Healthy Teeth ____ Feeding my baby ____ Healthy Food Shopping

____Feeding my child ____ Parenting

____ Physical activity for the whole family

____ Alternatives to TV watching

____ Eating Right During Pregnancy

2. What would be the best way for you to learn at WIC? (p.14, #1)

1. Lecture
2. Discussion
3. Hands-on activity
4. Video
5. One-on-one with nutritionist
6. One-on-one with peer

1. Was there anything else that you or your family needed help with today?(P. 17, # 10) ____ YES ____ NO

If YES, please place a check next to ALL the things you needed help with today:

____ Transportation ____ Food ____ Clothing

____ House/apartment concerns ____ Money issues ____ Parenting ideas

____ Child Care ____Fighting at home

____ Finding a job ____Child behavior concerns

____ School or job training ____ Other

2. What other services could WIC offer that would be helpful to you and your family?

1. If a baby wants a bottle at bedtime, what is the best choice? (p.18, #2)

1. whole milk
2. fruit juice
3. water
4. formula

2. When is the best time to stop giving a baby a bottle? (p.18, #4)

1. when a baby is crawling
2. when the baby can drink from a cup without spilling
3. after the baby is two years old
4. when the baby is 12 to 18 months old

3. A baby doesn’t need solid foods until she is 4 to 6 months old. (p.19, #10)

____ yes ____ no

1. On a scale of 1 to 10 (have a picture of this scale to hold up) where 1 is not important at all and 10 is very important, how important would you say that being physically fit is to you? (P. 45, #4)

Why?

2. How would you compare yourself to others of your own sex and age in terms of physical ability and fitness: (P. 80, #2)

1. Poor
2. Below Average
3. Average
4. Above Average
5. Excellent

1. Very inactive
2. Inactive
3. Average
4. Active
5. Very Active

1. If a person is fat, what do you think are the reasons? (P. 114, # 34)

A. They don’t exercise enough …………………… ÿ ÿ

B. They have big bones …………………………… ÿ ÿ

C. They have a gland problem or something is

wrong with their body …………………………. ÿ ÿ

D. They eat the wrong foods ……………………… ÿ ÿ

E. They don’t control themselves ………………… ÿ ÿ

F. They eat a lot of snacks ………………………… ÿ ÿ

G. They eat a lot …………………………………… ÿ ÿ

H. It is natural for them to be fat ………………….. ÿ ÿ

1. How strongly do you agree or disagree with the following? (P.4, #7)

I usually feel like eating something:

Strongly Strongly Doesn’t

Agree Agree Disagree Disagree Matter

A. When I’m nervous ………….. ÿ ÿ ÿ ÿ ÿ

B. When I’m under pressure …... ÿ ÿ ÿ ÿ ÿ

C. When I’m bored ……………. ÿ ÿ ÿ ÿ ÿ

D. When I’m sad ………………. ÿ ÿ ÿ ÿ ÿ

E. When I’m happy ……………. ÿ ÿ ÿ ÿ ÿ

F. When things aren’t going my wayÿ ÿ ÿ ÿ ÿ

G. When I’m mad ……………… ÿ ÿ ÿ ÿ ÿ

H. When I’m celebrating ………. ÿ ÿ ÿ ÿ ÿ

 

2. I make sure my child does not eat too many sweets, junk foods, or favorite foods.

Always Usually Sometimes Almost Never Never

3. I am especially careful to make sure my child eats enough.

Always Usually Sometimes Almost Never Never

4. I am especially careful to make sure my child eats enough of the right foods.

Always Usually Sometimes Almost Never Never

6. How would you describe your child’s eating habits? Please answer questions A through H, marking the best answer for each one. (P. 103, #10)

Never or

Almost Usually

Never Sometimes or Always

A. My child eats too much ……… ÿ ÿ ÿ

B. My child eats too little ………. ÿ ÿ ÿ

C. My child eats too many snacks.. ÿ ÿ ÿ

D. My child eats too little variety .. ÿ ÿ ÿ

E. My child is a picky eater ……… ÿ ÿ ÿ

F. My child eats only one or two

foods for several days at

a time ……………………. ÿ ÿ ÿ

G. My child eats very large

amounts of one food

at a time ………………… ÿ ÿ ÿ

H. My child eats the wrong kinds

of food …………………. ÿ ÿ ÿ

7. How does your family USUALLY eat the evening meal? (Mark the ONE best answer.) (P. 110, # 28)

We sit down together …………………… ÿ 1

We eat at different times ……………….. ÿ 2

 

8. I eat while I watch TV. (Circle one) (P. 149, H)

Never or Almost Never Sometimes Usually or Always

 

 

 

9. How many serving of fruit do you eat each day? (p.1, #2)

______________________

10. How many servings of vegetables do you eat each day? (p.1, #5)

______________________

11. Do you take the skin off the chicken? (p.1, #9)

____ yes ____ no

12. Which of the following was the most useful when deciding how to feed your baby?

(p.15, #7)

Talking with WIC staff ____ Talking with other WIC participants ____

Classes on feeding babies ____ Handouts you got at WIC appointments ___

13. Do you worry about whether your food will run out before you can buy more? (p.2, #14)

____ Yes ____ No

14. Do you sometimes run out of food before the end of the month? (p.2, #15)

____ Yes ____ No

 

16. Please answer the following questions concerning the way foods are prepared in your household. (P. 108, # 26)

it fried? ………………. ÿ ÿ ÿ ÿ

B. When you have chicken,

is it fried? ……………. ÿ ÿ ÿ ÿ

1. When you have vegetables,

is butter, margarine, salt pork,

ham hocks, or meat drippings

added to them? …………. ÿ ÿ ÿ ÿ

2. When you have salad, is

1. I don’t feel safe walking on my street (P. 3, #24)…..[NO] [YES]

1. I sometimes or rarely do physical activities like dancing, exercising, or sports because: (P. 5, #12) (Please check YES or NO after each of the following statements.)

YES NO

A. I look bad when I do them ……………………….. ÿ ÿ

B. They don’t interest me …………………………… ÿ ÿ

C. I don’t have time ………………………………… ÿ ÿ

D. I’m too tired ……………………………………... ÿ ÿ

E. I’d have to do them alone ……………………….. ÿ ÿ

F. I’m bad at them …………………………………. ÿ ÿ

G. I might get hurt ………………………………….. ÿ ÿ

H. There’s no place to do them …………………….. ÿ ÿ

I. It’s not safe to go outside ……………………….. ÿ ÿ

J. I have a long-standing medical condition or disability ÿ ÿ

2. Is there any type of physical activity that you and your children like to do together? If YES, what? (P. 45, #9)

____________________________________________________________________

How often do you do this activity? __________________________________

3. In the past 7 days, how many times did you do the following kinds of exercise for more than 15 minutes? (P. 81, #1)

TIMES PER WEEK

______ a) STRENUOUS EXERCISE (Heart Beats Rapidly) (i.e. running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, judo, roller skating, vigorous swimming, vigorous long distance bicycling)

______ b) MODERATE EXERCISE (Not Exhausting) (i.e. fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, dancing)

______ c) MILD EXERCISE (Low Effort) (i.e. yoga, easy walking, archery, fishing, bowling, horseshoes, golf, snow-mobiling)

4. Think about a 7-day period (a week). During your free time, how often do you do any physical activity long enough to work up a sweat (heart beats rapidly)? (P.81, #2)

1. Is anyone here worried about their child’s weight? (p. 39, #5)
2. What kinds of helpful advice has WIC given you? What kind of information would you like from WIC? (p. 41, #12)
3. How do you know when your child is hungry? (p. 36)

• How can you tell?
• What do you do when you are at home?
• What do you do if you are not at home and are out?
• Are there times when you knew your child was hungry, but you didn't have enough food at the time? What did you do in those situations?

1. What do you do if you want your child to try a new food? (p.44)
2. If your child won’t eat something you offer, what do you usually do? (P.44)
3. Where do you usually get information when you have questions about

feeding your child? (p. 37)

4. What advice do you receive from family and friends about feeding your children?
5. What do you think "being active" means when we’re talking about pre-school children? (P.43)
6. What kinds of physical activities do you do with your children? (P. 43)
7. Are there reasons why you can’t more physical activity to your day? (P.43)
8. What is your biggest problem when it comes to feeding your children? (P.44)