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pdfAppendix A-5
Program Data Collection Form for the Local WIC Agency
Local WIC Agency
Program Information Form
Implementation Study of the Loving Support Peer Counseling Program
(This form will be sent to local WIC agencies 2 weeks prior to the site visit to prepare so they are
able to prepare for the interview.)
OMB Clearance Number: xxxx-xxxx
Expiration Date: xx/xx/xxxx
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-XXXX. The time
required to complete this information collection is estimated to average 60 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. If you
have any comments concerning the accuracy of time estimates or suggestions for improving this
form, please contact: U. S. Department of Agriculture, Food and Nutrition Service, ORNA,
Alexandria, VA 22302.
Program Data to Be Collected
Thank you for participating in the implementation study of the Loving Support peer counseling
program. As you know, we will be conducting a site visit with you to learn more about how your
agency implements the program. As part of the site visit, we will ask you for some information
about your program operations, which you might like to prepare ahead of time. If you would
prefer to, you can complete the information now or you can wait and the site visitor will
complete it with you. For each of the items, we will also be asking for more contextual details.
Loving Support Peer Counseling/Breastfeeding Coordinator
A. What are the breastfeeding coordinator’s duties as they relate to Loving Support peer counseling?
Supervise and monitor work performance of Loving Support peer counselors
Develop basic policies and procedures for local Loving Support peer counseling program
Conduct needs assessment to target the WIC Loving Support peer counseling services
Provide training to local WIC staff (other than peer counselors) about breastfeeding and
peer counseling
Provide training to peer counselors about peer counseling duties and responsibilities
Initiate or serve as point of contact for community organizations that collaborate on
Loving Support peer counseling activities
Develop and implement outreach strategies for Loving Support peer counseling
Design and/or participate in evaluation of local WIC peer counseling services
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Conduct Loving Support program promotion with local organizations in the community
Provide information to WIC clients about the peer counseling program
Monitor Loving Support peer counseling implementation (e.g., peer counseling caseloads,
number of women served, breastfeeding initiation and duration rates among WIC
participants, etc.)
Report on the program operations to State WIC administrative staff
Other (Specify:)
B. Is any of his/her salary supported by the FNS peer counseling grant?
Yes, fully supported by Loving Support peer counseling funding
Yes, partially supported by Loving Support peer counseling funding
No, not funded by Loving Support peer counseling funding
Loving Support Peer Counselors
Please list the first names of each of your peer counselors, and indicate the number of hours per week, on
average, that they work and the percentage of their salaries/earnings that are supported by the FNS peer
counseling grant.
Peer Counselor Names and Staffing Chart
First Name
Peer Counselor #1
Peer Counselor #2
Peer Counselor #3
Peer Counselor #4
Peer Counselor #5
Peer Counselor #6
Peer Counselor #7
Hours
Worked/
Week
Supported by
FNS peer
counseling
grant?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
IF YES, %
salary/earnings
supported by
FNS peer
counseling grant
%
%
%
%
%
%
%
C. Do you have a written job description for Loving Support peer counselors?
No
Yes
**If yes, please provide us with a copy of the job description.
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Loving Support Peer Counseling Service Delivery Sites
Please indicate the local service delivery sites/clinics that offer Loving Support peer counseling.
Please tell us the monthly number of WIC participants, the monthly number of Loving Support
peer counseling participants, and the average number of Loving Support peer counseling
participants initiating breastfeeding per month, and indicate whether the site offers peer
counseling other than Loving Support.
Service Delivery Site Chart
Site # Site Name
Loving
Support
peer
counseling
offered?
Average # of WIC
participants per
month
Average # of
Loving Support
peer counseling
participants per
month
Average # of
Loving Support
peer counseling
participants that
initiated
Offers non-Loving
breastfeeding per Support peer
month
counseling?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Total
Please describe how the Loving Support peer counselors are allocated among your local
clinics/service delivery sites offering Loving Support peer counseling.
Percentage or hours/week of time at….
Site 1 (Name) Site 2 (Name) Site 3 (Name) Site 4 (Name) Site 5 (Name)
Peer counselor #1 (first
name)
Peer counselor #2 (first
name)
Peer counselor #3 (first
name)
Peer counselor #4 (first
name)
Peer counselor #5 (first
name)
Peer counselor #6 (first
name)
Peer counselor #7 (first
name)
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Information About Contacting WIC Participants
D. Do you track contacts with participants who receive Loving Support peer counseling each month?
No
Yes. If yes, please fill in the following information:
E. What is the average number of contacts made in a month for all peer counselors combined?
_______contacts per month
F. How do the contacts breakdown according to those that occur in the WIC offices, in the hospital, by
mail, over the phone, or other? In the last reported month, number of contacts;
___
in the WIC office
___
in the hospital
___
by mail
___
over the telephone
___
other (specify)
If possible, please provide us with a copy of a recent month’s report on Loving Support peer
counseling contacts.
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Policies about Frequency of Contact
In addition to responding to requests for assistance, do you have any general practice or policy
about the frequency of contact during the following time periods? (See table below.)
Frequency of Contact Chart
At least 1 time every…
No
guidelines
1 week
2 weeks
1
month
2
months
3
months
During 1st trimester
___ contacts per _____
During 2nd trimester
___ contacts per _____
During 3rd trimester
___ contacts per _____
___ contacts per _____
___ contacts per _____
___ contacts per _____
Other time period (Specify #
of contacts per time period)
During pregnancy
After Delivery
Week 1 (after hospital stay)
Weeks 2 – 4
Months 2 – 4
___ contacts per _____
Months 4 – 6
___ contacts per _____
After 6 Months
___ contacts per _____
G. The frequency of contact specified above is
General practice
More formal guidelines
A combination of general practice and guidelines
**If frequency of contact is determined by a combination of general practice and
guidelines, please explain.
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Documentation of Sessions
H. What do peer counselors record/document about peer counseling activities? (Select all that apply.)
I.
)
How is this information recorded?
J.
Location of contact
Method of contact (e.g., home visit, phone)
Topics/issues discussed with client
Unsuccessful contacts
Materials sent
Demographic information about mother and baby
Referrals made
Status of WIC participant in terms of initiation, duration, exclusivity of breastfeeding
Other (Specify:
On paper records
In local centralized data base
In state centralized data base
Other method (Please specify:______________________)
How often is this information recorded?
At each client contact
Once a week
Once every two weeks
Once a month
Other (Specify:__________________________________)
Documentation of Policies and Procedures
K. Please indicate for which of the following you have documented policies and/or procedures. (Check
all that apply.)
Compensation and reimbursement of peer counselors
Training
Documentation of client contacts
Peer counselor qualifications
Referral protocols
Confidentiality
Other (Specify:___________________________________)
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Costs/Funding
L. What is the time period for your organization’s fiscal year?
____ January 1 – December 31
____ July 1 – June 30
____ October 1 – September 30
____ Other (Specify: __________________________________________)
M. Please list the total labor and non-labor expenditures for your WIC agency for fiscal year 2007:
Labor costs (including salaries and fringe benefits)
$ _______________
Non-labor costs (including rent/mortgage/fee for the
space, utilities, professional fees, repair and maintenance,
office supplies and equipment, etc.)
$ _______________
N. Now we would like to find out about how Loving Support peer counseling was funded in your agency
during fiscal year 2007.
FNS Loving Support peer counseling funds
$ _______________
General funds from the Nutrition Services
Administration (NSA) used
for Loving Support peer counseling
$ _______________
State funds used for Loving Support peer counseling
$ _______________
Other non-WIC funds used for
Loving Support peer counseling
$ _______________
TOTAL funds for Loving Support peer counseling
from all sources
$_______________
If other non-WIC funds were used for Loving Support peer counseling, please
describe the source of funds.
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O. Now we would like to know how your agency spent its FNS peer counseling grant funding
during your fiscal year 2007. Please fill in all the lines in bold. Also fill in the other lines if
you have the information.
FNS Loving Support Peer
Counseling Grant
Expenditures
Salaries & benefits
Salaries
Fringe Benefits
Non-labor direct expenditures
Travel
Contract/ Purchased services
Capital equipment
Non-capital equipment and supplies
Indirect cost and occupancy expenditures (rent,
utilities, etc.)
Total expenditures for Loving Support peer
counseling
P. Overall, how much funding did your agency spend in FFY 07 to breastfeeding promotion services
other than FNS peer counseling grant funds?
$___________
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Loving Support Training
Loving Support Training Chart
In the table below, please indicate the types of training provide to WIC staff and peer counselors.
WIC Staff
Received once
Peer Counseling Staff
Received more
than once
Received once
Received more
than once
a. Loving Support peer counseling
training
b. Other locally and/or State-offered
training on breastfeeding and/or role of
peer counselors
c. Lactation management training
approved through IBCLSC Continuing
Education Recognition Points (CERPs)
d. Other lactation courses that award
certificates
e. Training in filling out paperwork or
data entry
f. Other (Specify:
________________________)
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Hospital Policy Chart
In the table below, please describe the policies for up to three hospitals where WIC participants
from your agency most frequently deliver.
a.
Has this hospital been designated a Baby-Friendly
Hospital, as outlined by UNICEF and the World
Health Organization?
b.
Is there rooming in for newborns?
c.
Are mothers encouraged to breastfeed within the first
hour after birth?
d.
Are breastfeeding infants routinely given any
supplementation, including water?
e.
Are formula discharge packs provided?
f.
Are there lactation consultants on staff?
g.
Have hospital staff received training in lactation
management in the last 3 years?
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Hospital A
Yes
No
Don’t know
IF YES, go to
Hospital B
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Hospital B
Yes
No
Don’t know
IF YES, go to
Hospital C
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Hospital C
Yes
No
Don’t know
IF YES, go to
question Q
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
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Data Collection Information
If you collect data on initiation, duration, or exclusivity, please respond to the following
questions
Q. How are these data collected?
Indicator
Breastfeeding
initiation
Breastfeeding
duration
Breastfeeding
exclusivity
In periodic paper or electronic reports
Collected by survey sent from State to all local WIC agencies for
completion
Other (Specify:) ___________________________________________
Other (Specify:) ___________________________________________
Other (Specify:) ___________________________________________
Entered into a state centralized data base
Entered into a local data base
R. How are these kept?
Indicator
Breastfeeding
initiation
Breastfeeding
duration
Breastfeeding
exclusivity
Stored in a local electronic spreadsheet or data base (e.g., Excel,
ACCESS or other data base)
Stored in a centralized state data base
Available in electronic document formats
Available in paper only
Other (Specify:) ___________________________________________
Other (Specify:) ___________________________________________
Other (Specify:) ___________________________________________
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S. How often are these data collected?
Indicator
Breastfeeding
initiation
Breastfeeding
duration
Breastfeeding
exclusivity
On an ongoing basis (at each client contact)
Monthly
Annually
Less often then annually
Other (Specify:) ___________________________________________
Other (Specify:) ___________________________________________
Other (Specify:) ___________________________________________
Less often than monthly but more often than once a year
T. How are these data used? (Select all that apply)
Needs assessment
Reporting to the State
For local evaluations of the Loving Support peer counseling program
Other (Specify:
)
Loving Support Peer Counseling Program Data
U. Which of these data items do you collect? (Select all that apply)
Overall number of WIC participants in Loving Support peer counseling
Number of pregnant WIC participants receiving Loving Support peer counseling
Number of postpartum WIC participants receiving Loving Support peer counseling
Type of prenatal Loving Support peer counseling received by individual participants
Frequency of prenatal Loving Support peer counseling received by individual participants
Type of Loving Support peer counseling received by individual participants after delivery
Frequency of Loving Support peer counseling received by individual participants after
delivery
Number of weeks or months over which postpartum Loving Support peer counseling services
are received by individual participants
Demographic information about Loving Support peer counseling participants (e.g., race, age)
)
Other (Specify:
None of the above (Skip to end.)
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V. How are these data used? (Select all that apply)
Needs assessment
Reporting to the State
For local evaluations of the Loving Support peer counseling program
Other (Specify:
)
W. How are the data above collected? (Select one)
Entered by peer counselors or other WIC staff into local centralized data base
Entered by peer counselors or other WIC staff into state centralized data base
Paper records are kept
A combination of the three methods
**Please explain which information is kept in which manner
Other (Specify:
)
X. How often are these data collected? (Select one)
On an ongoing basis
More than once a year
Annually
Less often then annually
Y. How are these data available at the local level? (Select one)
Accessible in local electronic spreadsheet or data base (e.g., Excel, ACCESS or other data
base)
Accessible from centralized state data base
Available in electronic document formats
Available in paper only
Not all data are in one format
**If the last box is checked, please specify the formats in which the data are available.
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| File Type | application/pdf |
| File Title | Microsoft Word - A-5 program data collection form-local agency.doc |
| Author | NicholsonJ |
| File Modified | 2007-12-21 |
| File Created | 2007-09-26 |