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Questionnaire

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| +------------------------------------------------------------------+  |
| | +-------------------------------------------------------------+  |  |
| | | Welcome!                                                    |  |  |
| | |                                                             |  |  |
| | | WIC is planning to change the types and amounts of food we  |  |  |
| | | give to WIC families. The new federal rules will allow      |  |  |
| | | families to receive new foods like fruits, vegetables, and  |  |  |
| | | whole grain bread while reducing some of the quantities of  |  |  |
| | | the current foods like milk, eggs, cheese, and juice. A     |  |  |
| | | PowerPoint presentation on the changes is available for     |  |  |
| | | your information at                                         |  |  |
| | | [[www                                                       |  |  |
| | | .wicworks.ca.gov]{.underline}](http://www.wicworks.ca.gov/) |  |  |
| | | under What\'s New.                                          |  |  |
| | |                                                             |  |  |
| | | The WIC program is trying to get ready for this big change  |  |  |
| | | and we need your help. We are asking you to answer some     |  |  |
| | | questions about the foods you buy/eat now, your opinion     |  |  |
| | | about some other foods that WIC may start offering, and     |  |  |
| | | your input about how to best educate WIC participants about |  |  |
| | | the changes. Your responses will help the California WIC    |  |  |
| | | program plan how to promote the improvements in the foods   |  |  |
| | | we give to families and how to educate participants about   |  |  |
| | | the specific changes they will see in WIC. Anything you     |  |  |
| | | tell us will be confidential and the survey will take about |  |  |
| | | ten minutes of your time.                                   |  |  |
| | |                                                             |  |  |
| | | Thank you.                                                  |  |  |
| | +-------------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

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| +------------------------------------------------------------------+  |
| |                                                                  |  |
| | ----- ---------------------------------------------------------- |  |
| |                                                                  |  |
| |  1\)   Please answer all the questions below. (Enter 0 if none.) |  |
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| |                                                                  |  |
| | ----- ---------------------------------------------------------- |  |
| |                                                                  |  |
| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| | | In                                                             |  |
| | cluding yourself, how many people currently live in    |   |   | |  |
| | | yo                                                             |  |
| | ur household?                                          |   |   | |  |
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| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| | | Ho                                                             |  |
| | w many are adults age 18 years and older?              |   |   | |  |
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| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| | | Ho                                                             |  |
| | w many are children between the ages of 6 and 18       |   |   | |  |
| | | ye                                                             |  |
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| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| | | Ho                                                             |  |
| | w many are children between the ages of 2 and 5 years? |   |   | |  |
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| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| | | Ho                                                             |  |
| | w many are children between the ages of 1 and 2 years? |   |   | |  |
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| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| | | Ho                                                             |  |
| | w many are children between the ages of birth and 1    |   |   | |  |
| | | ye                                                             |  |
| | ar?                                                    |   |   | |  |
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| | +---                                                             |  |
| | -------------------------------------------------------+---+---+ |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | When you shop for groceries, how many people do you     |  |  |
| | | \ | shop for?                                               |  |  |
| | | ) |                                                         |  |  |
| | |   |   ----------------------------------------------------  |  |  |
| | |   |                                                         |  |  |
| | |   |   ----------------------------------------------------  |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next few questions are about the type of milk  |  |
| |   you buy and drink.                                             |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What type(s) of milk do you usually buy for you and     |  |  |
| | | \ | your family?                                            |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select all that apply)                                 |  |  |
| | |   |                                                         |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   Whole milk (vitamin D milk) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](me                                                |  |  |
| | |   | dia/image2.png){width="0.21875in"   2% reduced fat milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![                                                    |  |  |
| | |   | ](media/image2.png){width="0.21875in"   1% low fat milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](me                                                |  |  |
| | |   | dia/image2.png){width="0.21875in"   Skim or nonfat milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   Powdered milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![                                                    |  |  |
| | |   | ](media/image2.png){width="0.21875in"   Evaporated milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png)                                 |  |  |
| | |   | {width="0.21875in"   Lactaid or other lactose free milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Soy milk    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Goat's milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   Do not buy any milk or soy milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What type of milk do **[you]{.underline}** drink [most  |  |  |
| | | \ | of the time]{.underline}?                               |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select [one]{.underline})                              |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------                       |  |  |
| | |   | ---------- -------------------------------------------- |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image3.png){width="0.21875in"   I don't drink milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](                                                  |  |  |
| | |   | media/image3.png){width="0.21875in"   Whole (vitamin D) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   2%          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   1%          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image3.png){width="0.21875in"   Skim (nonfat) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Lactaid     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Soy milk    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Goat's milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------                       |  |  |
| | |   | ---------- -------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 5 | Why do you drink this type of milk?                     |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply)                                 |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media/image                                       |  |  |
| | |   | 2.png){width="0.21875in"   It's best for me (healthier) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   My doctor told me to drink this |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](                                                  |  |  |
| | |   | media/image2.png){width="0.21875in"   WIC recommends it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![]                                                   |  |  |
| | |   | (media/image2.png){width="0.21875in"   I like the taste |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width=                          |  |  |
| | |   | "0.21875in"   It's the only type available where I shop |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](med                                               |  |  |
| | |   | ia/image2.png){width="0.21875in"   My family prefers it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   It\'s the cheapest |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="                         |  |  |
| | |   | 0.21875in"   I have lactose intolerance or milk allergy |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 6 | If asked to change from whole to 2% milk, how ready     |  |  |
| | | \ | would you be?                                           |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   !                                                     |  |  |
| | |   | [](media/image3.png){width="0.21875in"   I am ready now |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){wi                              |  |  |
| | |   | dth="0.21875in"   I am considering switching to 2% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.2                      |  |  |
| | |   | 1875in"   I have not thought about switching to 2% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age3.png){width="0.21875in"   I sometimes drink 2% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0                        |  |  |
| | |   | .21875in"   I would never consider switching to 2% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image3.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 7 | If asked to change from 2% to 1% milk, how ready would  |  |  |
| | | \ | you be?                                                 |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   !                                                     |  |  |
| | |   | [](media/image3.png){width="0.21875in"   I am ready now |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){wi                              |  |  |
| | |   | dth="0.21875in"   I am considering switching to 1% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.2                      |  |  |
| | |   | 1875in"   I have not thought about switching to 1% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age3.png){width="0.21875in"   I sometimes drink 1% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0                        |  |  |
| | |   | .21875in"   I would never consider switching to 1% milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image3.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 8 | What would make it easier for you to switch to a lower  |  |  |
| | | \ | fat milk (from whole to 2% or from 2% to 1%)?           |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](me                                                |  |  |
| | |   | dia/image2.png){width="0.21875in"   If the cost is less |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](                                                  |  |  |
| | |   | media/image2.png){width="0.21875in"   If it tastes good |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2187                   |  |  |
| | |   | 5in"   If I learn that it has more vitamins, protein or |  |  |
| | |   |   height="0.21875in"}                       calcium     |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge2.png){width="0.21875in"   If my doctor recommends it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   If other family members want it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2187                   |  |  |
| | |   | 5in"   If I have quick/easy preparation ideas for using |  |  |
| | |   |   height="0.21875in"}                       it          |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Nothing     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 9 | Do you take care of a child **2-5 years old** in your   |  |  |
| | | \ | household?                                              |  |  |
| | | ) |                                                         |  |  |
| | |   |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Yes         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   No          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +-------------------------------------------------------------+  |  |
| | | If there are MULTIPLE 2-5 year old children in your         |  |  |
| | | household, please answer the following questions about the  |  |  |
| | | child whose name comes first in the alphabet.               |  |  |
| | |                                                             |  |  |
| | | Example: You care for 2 children in your household. Their   |  |  |
| | | names are Jane and John. Jane comes before John in the      |  |  |
| | | alphabet, so you would answer the next two questions by     |  |  |
| | | referring to Jane.                                          |  |  |
| | +-------------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | What type of milk does the **2 to 5 year old child** in |  |  |
| | | 0 | your household drink [most of the time?]{.underline}    |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one.]{.underline})                             |  |  |
| | |   |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.                       |  |  |
| | |   | 21875in"   I don\'t have a child age 2 to 5 years in my |  |  |
| | |   |   height="0.21875in"}                       household   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](me                                                |  |  |
| | |   | dia/image3.png){width="0.21875in"   Does not drink milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](                                                  |  |  |
| | |   | media/image3.png){width="0.21875in"   Whole (vitamin D) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   2%          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   1%          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image3.png){width="0.21875in"   Skim (nonfat) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Lactaid     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Soy milk    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Goat's milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | Why does the **2-5 year old child** in your household   |  |  |
| | | 1 | drink this type of milk?                                |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media/image2.png){width                           |  |  |
| | |   | ="0.21875in"   It's best for my child (most nutritious) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   The doctor recommended it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](                                                  |  |  |
| | |   | media/image2.png){width="0.21875in"   WIC recommends it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/i                                           |  |  |
| | |   | mage2.png){width="0.21875in"   My child likes the taste |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width=                          |  |  |
| | |   | "0.21875in"   It's the only type available where I shop |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](med                                               |  |  |
| | |   | ia/image2.png){width="0.21875in"   My family prefers it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   It\'s the cheapest |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21                     |  |  |
| | |   | 875in"   My child has lactose intolerance or allergy to |  |  |
| | |   |   height="0.21875in"}                       milk        |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: Because you said that you buy soy milk, we would   |  |
| |   like to know a little more about soy milk consumption in your  |  |
| |   household.                                                     |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | How often do **you** drink soy milk?                    |  |  |
| | | 2 |                                                         |  |  |
| | | \ | (Select [one.]{.underline})                             |  |  |
| | | ) |                                                         |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){                                |  |  |
| | |   | width="0.21875in"   I don\'t drink soy milk (go to Q14) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge3.png){width="0.21875in"   I drink soy milk regularly |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3                                      |  |  |
| | |   | .png){width="0.21875in"   I drink soy milk occasionally |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | Why do **you** drink soy milk?                          |  |  |
| | | 3 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media                                             |  |  |
| | |   | /image2.png){width="0.21875in"   I don't drink soy milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.                       |  |  |
| | |   | 21875in"   I have a lactose intolerance or milk allergy |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){wid                             |  |  |
| | |   | th="0.21875in"   I don't like the taste of regular milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image                                       |  |  |
| | |   | 2.png){width="0.21875in"   I like the taste of soy milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.                                     |  |  |
| | |   | png){width="0.21875in"   Soy milk is good for my health |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | Why does your child drink soy milk?                     |  |  |
| | | 4 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](medi                                              |  |  |
| | |   | a/image2.png){width="0.21875in"   I don\'t have a child |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.                                     |  |  |
| | |   | png){width="0.21875in"   He/she does not drink soy milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2187                   |  |  |
| | |   | 5in"   He/she has a lactose intolerance or milk allergy |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21                     |  |  |
| | |   | 875in"   He/she does not like the taste of regular milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png                                  |  |  |
| | |   | ){width="0.21875in"   He/she like the taste of soy milk |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){                                |  |  |
| | |   | width="0.21875in"   Soy milk is good for his/her health |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.218                    |  |  |
| | |   | 75in"   Because another person in the family drinks soy |  |  |
| | |   |   height="0.21875in"}                       milk        |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next question is about tofu.                   |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | Do you ever buy tofu for your family? (Do not answer    |  |  |
| | | 5 | yes if you only buy prepared tofu at a restaurant.)     |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   ---------------------------                           |  |  |
| | |   | -------------- ---------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Yes         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   No          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ---------------------------                           |  |  |
| | |   | -------------- ---------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | What is the reason you don\'t buy tofu?                 |  |  |
| | | 6 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge2.png){width="0.21875in"   I don\'t know what tofu is |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/                                            |  |  |
| | |   | image2.png){width="0.21875in"   I have never tried tofu |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){widt                            |  |  |
| | |   | h="0.21875in"   I don\'t like the taste/texture of tofu |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   I do not know how to prepare it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2                                      |  |  |
| | |   | .png){width="0.21875in"   I am allergic to soy products |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   My family does not eat tofu |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next few questions will ask about fruits and   |  |
| |   vegetables (this does not include juice).                      |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | How often do you eat:                                   |  |  |
| | | 7 |                                                         |  |  |
| | | \ | (Read the options and select one for each form):        |  |  |
| | | ) |                                                         |  |  |
| | +---+---------------------------------------------------------+  |  |
| |                                                                  |  |
| |   -- -------- -----------------                                  |  |
| | ------------------------ --------------------------------------- |  |
| | -- ----------------------------------------- ------------------- |  |
| | ---------------------- ----------------------------------------- |  |
| |               Daily                                     Wee      |  |
| | kly                                    Monthly                   |  |
| |                  Once in a while                           Never |  |
| |                                                                  |  |
| |      Fresh    ![](media/image                                    |  |
| | 3.png){width="0.21875in"   ![](media/image3.png){width="0.21875i |  |
| | n"   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |      frui                                                        |  |
| | ts   height="0.21875in"}                       height="0.21875in |  |
| | "}                       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |      Canned   ![](media/image                                    |  |
| | 3.png){width="0.21875in"   ![](media/image3.png){width="0.21875i |  |
| | n"   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |      frui                                                        |  |
| | ts   height="0.21875in"}                       height="0.21875in |  |
| | "}                       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |      Frozen   ![](media/image                                    |  |
| | 3.png){width="0.21875in"   ![](media/image3.png){width="0.21875i |  |
| | n"   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |      frui                                                        |  |
| | ts   height="0.21875in"}                       height="0.21875in |  |
| | "}                       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |   -- -------- -----------------                                  |  |
| | ------------------------ --------------------------------------- |  |
| | -- ----------------------------------------- ------------------- |  |
| | ---------------------- ----------------------------------------- |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | How often do you eat:                                   |  |  |
| | | 8 |                                                         |  |  |
| | | \ | (Read the options and select one for each form):        |  |  |
| | | ) |                                                         |  |  |
| | +---+---------------------------------------------------------+  |  |
| |                                                                  |  |
| |   -- ------------ -----------------                              |  |
| | ------------------------ --------------------------------------- |  |
| | -- ----------------------------------------- ------------------- |  |
| | ---------------------- ----------------------------------------- |  |
| |                   Daily                                     Wee  |  |
| | kly                                    Monthly                   |  |
| |                  Once in a while                           Never |  |
| |                                                                  |  |
| |      Fresh        ![](media/image                                |  |
| | 3.png){width="0.21875in"   ![](media/image3.png){width="0.21875i |  |
| | n"   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |      vegetabl                                                    |  |
| | es   height="0.21875in"}                       height="0.21875in |  |
| | "}                       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |      Canned       ![](media/image                                |  |
| | 3.png){width="0.21875in"   ![](media/image3.png){width="0.21875i |  |
| | n"   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |      vegetabl                                                    |  |
| | es   height="0.21875in"}                       height="0.21875in |  |
| | "}                       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |      Frozen       ![](media/image                                |  |
| | 3.png){width="0.21875in"   ![](media/image3.png){width="0.21875i |  |
| | n"   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |      vegetabl                                                    |  |
| | es   height="0.21875in"}                       height="0.21875in |  |
| | "}                       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |   -- ------------ -----------------                              |  |
| | ------------------------ --------------------------------------- |  |
| | -- ----------------------------------------- ------------------- |  |
| | ---------------------- ----------------------------------------- |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 1 | What might help you eat more fruits and vegetables?     |  |  |
| | | 9 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media/image2.png){width="                         |  |  |
| | |   | 0.21875in"   I already eat enough fruits and vegetables |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image                                       |  |  |
| | |   | 2.png){width="0.21875in"   Quick/easy preparation ideas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width                           |  |  |
| | |   | ="0.21875in"   Information on nutrition/health benefits |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Lower price |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   If other family members want it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2187                   |  |  |
| | |   | 5in"   Opportunities to taste new fruits and vegetables |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Nothing     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | Do you take care of a child **1-5 year old** in your    |  |  |
| | | 0 | household?                                              |  |  |
| | | \ |                                                         |  |  |
| | | ) |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Yes         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   No          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +-------------------------------------------------------------+  |  |
| | | If there are MULTIPLE **1-5** year old children in your     |  |  |
| | | household, please answer the following questions about the  |  |  |
| | | child whose name comes first in the alphabet.               |  |  |
| | |                                                             |  |  |
| | | Example: You care for 2 children in your household. Their   |  |  |
| | | names are Jane and John. Jane comes before John in the      |  |  |
| | | alphabet, so you would answer the next two questions by     |  |  |
| | | referring to Jane.                                          |  |  |
| | +-------------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next two questions are about the kind of       |  |
| |   juice WIC gives.                                               |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | How many times a day does the **1-5 year old** child in |  |  |
| | | 1 | your household usually drink the kind of juice WIC      |  |  |
| | | \ | gives?                                                  |  |  |
| | | ) |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   The child in my household does not drink juice |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   1           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   2           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   3           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   4           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   5           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   6           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   7           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   8           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   9           |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   10          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | Each time the **1-5 year old** child in your household  |  |  |
| | | 2 | drinks juice, what is the typical amount?               |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Use a measuring cup to estimate amount)                |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------                         |  |  |
| | |   | ------------ ------------------------------------------ |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Up to 4 oz  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   5-7 oz      |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   8-11 oz     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   12-15 oz    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image3.png){width="0.21875in"   16 oz or more |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------                         |  |  |
| | |   | ------------ ------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | When you give juice to the **1-5 year old** child in    |  |  |
| | | 3 | your household, do you dilute the juice with water?     |  |  |
| | | \ |                                                         |  |  |
| | | ) |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Yes         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   No          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next few questions are about sweetened         |  |
| |   beverages.                                                     |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | What sweetened beverages do **you** consume three or    |  |  |
| | | 4 | more times a week?                                      |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media/                                            |  |  |
| | |   | image2.png){width="0.21875in"   Sports or energy drinks |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   Regular sodas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Diet sodas  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){wi                              |  |  |
| | |   | dth="0.21875in"   Sugar sweetened beverages from powder |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.pn                                   |  |  |
| | |   | g){width="0.21875in"   Sugar-free beverages from powder |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2                                      |  |  |
| | |   | .png){width="0.21875in"   Fruit drinks (not 100% juice) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   Sugar-free Flavored water |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.                                     |  |  |
| | |   | png){width="0.21875in"   Sweetened tea/coffee beverages |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   None        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | What might help you consume less sugar sweetened        |  |  |
| | | 5 | beverages?                                              |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.21                     |  |  |
| | |   | 875in"   Information on other beverages that are better |  |  |
| | |   |   height="0.21875in"}                       for me      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width=                          |  |  |
| | |   | "0.21875in"   If other family members stop wanting them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21                     |  |  |
| | |   | 875in"   Information on why sweetened beverages are not |  |  |
| | |   |   heigh                                                 |  |  |
| | |   | t="0.21875in"}                       good for my health |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   If my doctor recommends that I should limit |  |  |
| | |   |   height                                                |  |  |
| | |   | ="0.21875in"}                       sweetened beverages |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   I am not interested in decreasing intake of |  |  |
| | |   |   height                                                |  |  |
| | |   | ="0.21875in"}                       sweetened beverages |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | What sweetened beverages does the **1-5 year old        |  |  |
| | | 6 | child** in your household drink?                        |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](media/                                            |  |  |
| | |   | image2.png){width="0.21875in"   Sports or energy drinks |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   Regular sodas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Diet sodas  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){wi                              |  |  |
| | |   | dth="0.21875in"   Sugar sweetened beverages from powder |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.pn                                   |  |  |
| | |   | g){width="0.21875in"   Sugar-free beverages from powder |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2                                      |  |  |
| | |   | .png){width="0.21875in"   Fruit drinks (not 100% juice) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   Sugar-free Flavored water |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.                                     |  |  |
| | |   | png){width="0.21875in"   Sweetened tea/coffee beverages |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   None        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | Why do you give sweetened beverages to the **1-5 year   |  |  |
| | | 7 | old child** in your household?                          |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I don\'t see the harm in it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){w                               |  |  |
| | |   | idth="0.21875in"   Other family members also drink them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.                       |  |  |
| | |   | 21875in"   I don\'t know what other beverage to provide |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21                     |  |  |
| | |   | 875in"   My child (the child in your household) prefers |  |  |
| | |   |   he                                                    |  |  |
| | |   | ight="0.21875in"}                       sweet beverages |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.218                    |  |  |
| | |   | 75in"   My child (the child in your household) does not |  |  |
| | |   |   height                                                |  |  |
| | |   | ="0.21875in"}                       like to drink water |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next questions are about organic foods.        |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | Do you ever buy organic foods?                          |  |  |
| | | 8 |                                                         |  |  |
| | | \ | (Select [one]{.underline}.)                             |  |  |
| | | ) |                                                         |  |  |
| | |   |   ---------------------------                           |  |  |
| | |   | -------------- ---------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Yes         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   No          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ---------------------------                           |  |  |
| | |   | -------------- ---------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 2 | What type of organic foods do you buy for you and your  |  |  |
| | | 9 | family?                                                 |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ---------------------------------                     |  |  |
| | |   | -------- ---------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Milk        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Fruits      |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Vegetables  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Eggs        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Cereals     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Bread       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Meat        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge2.png){width="0.21875in"   I do not buy organic foods |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ---------------------------------                     |  |  |
| | |   | -------- ---------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What is your opinion about organic foods?               |  |  |
| | | 0 |                                                         |  |  |
| | | \ | (Select all that apply)                                 |  |  |
| | | ) |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   I feel that organic foods are better for me |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   I think organic foods are no different from |  |  |
| | |   |                                                         |  |  |
| | |   | height="0.21875in"}                       regular foods |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.218                    |  |  |
| | |   | 75in"   I feel regular (non-organic) foods are a better |  |  |
| | |   |   height="0.21875in"}                       choice      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width=                          |  |  |
| | |   | "0.21875in"   I don't know anything about organic foods |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2                      |  |  |
| | |   | 1875in"   I don\'t have a strong opinion one way or the |  |  |
| | |   |   height="0.21875in"}                       other       |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | Which of the following statements do you agree with?    |  |  |
| | | 1 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.2                      |  |  |
| | |   | 1875in"   Organic foods are usually more expensive than |  |  |
| | |   |   height="0.2187                                        |  |  |
| | |   | 5in"}                       regular (non-organic) foods |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.                       |  |  |
| | |   | 21875in"   Organic foods usually cost about the same as |  |  |
| | |   |   height="0.2187                                        |  |  |
| | |   | 5in"}                       regular (non-organic) foods |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.218                    |  |  |
| | |   | 75in"   Organic foods are too expensive for most people |  |  |
| | |   |   height="0.21875in"}                       to buy      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="                         |  |  |
| | |   | 0.21875in"   I am willing to pay more for organic foods |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="                         |  |  |
| | |   | 0.21875in"   I don\'t know anything about organic foods |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next few questions will ask about the bread    |  |
| |   and grain products you buy for your family.                    |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | For each item listed below, identify if you buy it for  |  |  |
| | | 2 | your family. Do not include items eaten at a            |  |  |
| | | \ | restaurant.                                             |  |  |
| | | ) |                                                         |  |  |
| | |   | (Read the list and select an answer for each item.)     |  |  |
| | +---+---------------------------------------------------------+  |  |
| |                                                                  |  |
| |   --- ---------------------                                      |  |
| | -- ----------------------------------------- ------------------- |  |
| | ---------------------- ----------------------------------------- |  |
| |                               Yes                                |  |
| |             No                                        Don't know |  |
| |                                                                  |  |
| |       whole wheat bread o                                        |  |
| | r    ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |  whole grain bread       height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       white bread                                                |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       corn tortillas                                             |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       whole wheat tortill                                        |  |
| | as   ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       flour tortillas                                            |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       oatmeal (not instan                                        |  |
| | t    ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |  oatmeal packets)        height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       brown rice                                                 |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       white rice                                                 |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       barley                                                     |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |                                                                  |  |
| |       bulgur                                                     |  |
| |      ![](media/image3.png){width="0.21875in"   ![](media/image3. |  |
| | png){width="0.21875in"   ![](media/image3.png){width="0.21875in" |  |
| |                                                                  |  |
| |                          height="0.21875in"}                     |  |
| |    height="0.21875in"}                       height="0.21875in"} |  |
| |   --- ---------------------                                      |  |
| | -- ----------------------------------------- ------------------- |  |
| | ---------------------- ----------------------------------------- |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What is the reason you don't buy whole wheat or whole   |  |  |
| | | 3 | grain breads?                                           |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){w                               |  |  |
| | |   | idth="0.21875in"   I don't know what these products are |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png)                                 |  |  |
| | |   | {width="0.21875in"   I have never tasted these products |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I don't like how they taste |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   My family doesn't like them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   They cost too much |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   Someone in the family has a food allergy or |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                     medical reason not to eat that food |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width                           |  |  |
| | |   | ="0.21875in"   I can't find these products in the store |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   No specific reason |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What is the reason you don\'t buy corn tortillas?       |  |  |
| | | 4 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge2.png){width="0.21875in"   I don't know what they are |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/i                                           |  |  |
| | |   | mage2.png){width="0.21875in"   I have never tasted them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   I make my own tortillas at home |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I don't like how they taste |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   My family doesn't like them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   They cost too much |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   Someone in the family has a food allergy or |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                     medical reason not to eat that food |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.                                     |  |  |
| | |   | png){width="0.21875in"   I can't find them in the store |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I just don\'t eat tortillas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What is the reason you don\'t buy whole wheat           |  |  |
| | | 5 | tortillas?                                              |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge2.png){width="0.21875in"   I don't know what they are |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/i                                           |  |  |
| | |   | mage2.png){width="0.21875in"   I have never tasted them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   I make my own tortillas at home |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I don't like how they taste |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   My family doesn't like them |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   They cost too much |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   Someone in the family has a food allergy or |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                     medical reason not to eat that food |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.                                     |  |  |
| | |   | png){width="0.21875in"   I can't find them in the store |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I just don\'t eat tortillas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What is the reason you don\'t buy brown rice?           |  |  |
| | | 6 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/                                            |  |  |
| | |   | image2.png){width="0.21875in"   I don't know what it is |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media                                             |  |  |
| | |   | /image2.png){width="0.21875in"   I have never tasted it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/imag                                        |  |  |
| | |   | e2.png){width="0.21875in"   I don't know how to cook it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   It takes too long to cook |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/ima                                         |  |  |
| | |   | ge2.png){width="0.21875in"   I don't like how it tastes |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   My family doesn't like it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](                                                  |  |  |
| | |   | media/image2.png){width="0.21875in"   It costs too much |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0                        |  |  |
| | |   | .21875in"   Someone in the family has a food allergy or |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                     medical reason not to eat that food |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image                                       |  |  |
| | |   | 2.png){width="0.21875in"   I can't find it in the store |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   No specific reason |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Don't know  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What do you think might help you consider increasing    |  |  |
| | | 7 | your consumption of whole grains?                       |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png                                  |  |  |
| | |   | ){width="0.21875in"   I already eat enough whole grains |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="                         |  |  |
| | |   | 0.21875in"   Opportunity to taste new whole grain foods |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.pn                                   |  |  |
| | |   | g){width="0.21875in"   Quick and easy preparation ideas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){                                |  |  |
| | |   | width="0.21875in"   Knowing which foods are whole grain |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width                           |  |  |
| | |   | ="0.21875in"   Information on nutrition/health benefits |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/                                            |  |  |
| | |   | image2.png){width="0.21875in"   If doctor recommends it |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21                     |  |  |
| | |   | 875in"   If other family members also want to eat these |  |  |
| | |   |   height="0.21875in"}                       foods       |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   | ![](media/image2.png){width="0.21875in"   I don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Nothing     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next two questions will ask about beans.       |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | Which of the following items do you buy?                |  |  |
| | | 8 |                                                         |  |  |
| | | \ | (Select all that apply)                                 |  |  |
| | | ) |                                                         |  |  |
| | |   |   -----------------------------                         |  |  |
| | |   | ------------ ------------------------------------------ |  |  |
| | |   |                                                         |  |  |
| | |   |  ![](media/image2.png){width="0.21875in"   Canned beans |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Dried beans |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   None        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------                         |  |  |
| | |   | ------------ ------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 3 | What is the reason you use canned beans?                |  |  |
| | | 9 |                                                         |  |  |
| | | \ | (Select all that apply.)                                |  |  |
| | | ) |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){wi                              |  |  |
| | |   | dth="0.21875in"   It takes too long to cook dried beans |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width                           |  |  |
| | |   | ="0.21875in"   I don\'t know how to prepare dried beans |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width=                          |  |  |
| | |   | "0.21875in"   It is more convenient to use canned beans |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875                  |  |  |
| | |   | in"   Canned beans taste better than cooked dried beans |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What is your opinion about offering baby foods (plain   |  |  |
| | | 0 | fruits and vegetables for all and plain meat for fully  |  |  |
| | | \ | breastfed infants) in the WIC food package?             |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.                       |  |  |
| | |   | 21875in"   WIC should offer baby foods because they are |  |  |
| | |   |   heig                                                  |  |  |
| | |   | ht="0.21875in"}                       convenient to use |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.                       |  |  |
| | |   | 21875in"   WIC should offer baby foods to help families |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |      introduce fruits and vegetables after their babies |  |  |
| | |   |                                                         |  |  |
| | |   |                                      are six months old |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){widt                            |  |  |
| | |   | h="0.21875in"   WIC should not offer baby foods because |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |             participants can prepare baby foods at home |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2187                   |  |  |
| | |   | 5in"   WIC should not offer baby foods because they are |  |  |
| | |   |   height="0.21875in"}                       expensive   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.2                      |  |  |
| | |   | 1875in"   I don\'t have any opinion about offering baby |  |  |
| | |   |   height="0.21875i                                      |  |  |
| | |   | n"}                       foods in the WIC food package |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +-------------------------------------------------------------+  |  |
| | | Transition: As you may know, the new rule decreases the     |  |  |
| | | amount of milk, eggs, cheese, and juice to make the food    |  |  |
| | | package more consistent with the 2005 U.S. Dietary          |  |  |
| | | Guidelines.                                                 |  |  |
| | |                                                             |  |  |
| | | The next few questions ask your opinion about the decrease  |  |  |
| | | in the amount of milk, cheese, eggs, and juice.             |  |  |
| | +-------------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What is your opinion about the decrease in the amount   |  |  |
| | | 1 | of milk?                                                |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I understand and enthusiastically support this |  |  |
| | |   |   height="0.21875in"}                       change      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I mostly understand the reason for this change and |  |  |
| | |   |   h                                                     |  |  |
| | |   | eight="0.21875in"}                       can support it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I am not sure I understand the reason for this |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |         change and I am not sure I support it, but I am |  |  |
| | |   |                                                         |  |  |
| | |   |                                   open to learning more |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I think this change is not good and I have serious |  |  |
| | |   |   heig                                                  |  |  |
| | |   | ht="0.21875in"}                       concerns about it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What is your opinion about the decrease in the amount   |  |  |
| | | 2 | of cheese?                                              |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I understand and enthusiastically support this |  |  |
| | |   |   height="0.21875in"}                       change      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I mostly understand the reason for this change and |  |  |
| | |   |   h                                                     |  |  |
| | |   | eight="0.21875in"}                       can support it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I am not sure I understand the reason for this |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |         change and I am not sure I support it, but I am |  |  |
| | |   |                                                         |  |  |
| | |   |                                   open to learning more |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I think this change is not good and I have serious |  |  |
| | |   |   heig                                                  |  |  |
| | |   | ht="0.21875in"}                       concerns about it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What is your opinion about the decrease in the amount   |  |  |
| | | 3 | of eggs?                                                |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I understand and enthusiastically support this |  |  |
| | |   |   height="0.21875in"}                       change      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I mostly understand the reason for this change and |  |  |
| | |   |   h                                                     |  |  |
| | |   | eight="0.21875in"}                       can support it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I am not sure I understand the reason for this |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |         change and I am not sure I support it, but I am |  |  |
| | |   |                                                         |  |  |
| | |   |                                   open to learning more |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I think this change is not good and I have serious |  |  |
| | |   |   heig                                                  |  |  |
| | |   | ht="0.21875in"}                       concerns about it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What is your opinion about the decrease in the amount   |  |  |
| | | 4 | of juice?                                               |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I understand and enthusiastically support this |  |  |
| | |   |   height="0.21875in"}                       change      |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I mostly understand the reason for this change and |  |  |
| | |   |   h                                                     |  |  |
| | |   | eight="0.21875in"}                       can support it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21                     |  |  |
| | |   | 875in"   I am not sure I understand the reason for this |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |         change and I am not sure I support it, but I am |  |  |
| | |   |                                                         |  |  |
| | |   |                                   open to learning more |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875i                 |  |  |
| | |   | n"   I think this change is not good and I have serious |  |  |
| | |   |   heig                                                  |  |  |
| | |   | ht="0.21875in"}                       concerns about it |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Don\'t know |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -------------------------------------                 |  |  |
| | |   | ---- -------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: We are finished with the food related questions.   |  |
| |   The next few questions are about education and training.       |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | In what ways would you like to share information on the |  |  |
| | | 5 | food package changes with WIC participants?             |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Handouts    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Classes     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   One-on-one contact |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Video       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2                                      |  |  |
| | |   | .png){width="0.21875in"   Interactive computer programs |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   E-mail      |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Internet    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![                                                    |  |  |
| | |   | ](media/image2.png){width="0.21875in"   Telephone calls |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| |                                                                  |  |
| | +---------------------------+---+------------------------------+ |  |
| | | If Other, please specify: |   |   -------------------------  | |  |
| | |                           |   |                              | |  |
| | |                           |   |   -------------------------  | |  |
| | +---------------------------+---+------------------------------+ |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | What training or teaching tools would you like to       |  |  |
| | | 6 | receive in preparation for educating WIC families on    |  |  |
| | | \ | the food package changes?                               |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | |   |   ![](me                                                |  |  |
| | |   | dia/image2.png){width="0.21875in"   Grocery store tours |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.pn                                   |  |  |
| | |   | g){width="0.21875in"   Potlucks/Taste-testing new foods |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media                                             |  |  |
| | |   | /image2.png){width="0.21875in"   Cooking demonstrations |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.pn                                   |  |  |
| | |   | g){width="0.21875in"   Quick and easy preparation ideas |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){wid                             |  |  |
| | |   | th="0.21875in"   Handouts and educational material kits |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   Learner-centered training |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Videos      |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](m                                                 |  |  |
| | |   | edia/image2.png){width="0.21875in"   Web-based training |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------------                   |  |  |
| | |   | ------ ------------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| |                                                                  |  |
| | +---------------------------+---+------------------------------+ |  |
| | | If Other, please specify: |   |   -------------------------  | |  |
| | |                           |   |                              | |  |
| | |                           |   |   -------------------------  | |  |
| | +---------------------------+---+------------------------------+ |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   -------------------------------------------------------------  |  |
| |   Transition: The next few questions are about you.              |  |
| |                                                                  |  |
| |   -------------------------------------------------------------  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | How many years have you worked for WIC?                 |  |  |
| | | 7 |                                                         |  |  |
| | | \ | (Select [one]{.underline}.)                             |  |  |
| | | ) |                                                         |  |  |
| | |   |   -----------------------------                         |  |  |
| | |   | ------------ ------------------------------------------ |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Less than 1 |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   1-2         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   3-5         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   6-10        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |                                                         |  |  |
| | |   |  ![](media/image3.png){width="0.21875in"   More than 10 |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   -----------------------------                         |  |  |
| | |   | ------------ ------------------------------------------ |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | Select the category that most closely describes your    |  |  |
| | | 8 | job classification:                                     |  |  |
| | | \ |                                                         |  |  |
| | | ) | (Select [one]{.underline}.)                             |  |  |
| | |   |                                                         |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.2                      |  |  |
| | |   | 1875in"   Administrator/Director/Coordinator/Supervisor |  |  |
| | |   |   height="0.2187                                        |  |  |
| | |   | 5in"}                       (not direct client service) |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   Registered Dietitian (RD) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/im                                          |  |  |
| | |   | age2.png){width="0.21875in"   Degreed Nutritionist (DN) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2                                      |  |  |
| | |   | .png){width="0.21875in"   WIC Nutrition Assistant (WNA) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.                       |  |  |
| | |   | 21875in"   Clerical staff or other job working with WIC |  |  |
| | |   |   height="0.21875in"}                       families    |  |  |
| | |   |   ------------------------------------                  |  |  |
| | |   | ----- ------------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 4 | Do you regularly provide training to WIC staff?         |  |  |
| | | 9 |                                                         |  |  |
| | | \ |   --------------                                        |  |  |
| | | ) | --------------------------- --------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Yes         |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   No          |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   --------------                                        |  |  |
| | |   | --------------------------- --------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 5 | What language do you speak most often at home?  (Select |  |  |
| | | 0 | [one]{.underline}.)                                     |  |  |
| | | \ |                                                         |  |  |
| | | ) |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   English     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Spanish     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Vietnamese  |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image                                       |  |  |
| | |   | 3.png){width="0.21875in"   Chinese (Cantonese/Mandarin) |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Russian     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Hmong       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Armenian    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| |                                                                  |  |
| | +---------------------------+---+------------------------------+ |  |
| | | If Other, please specify: |   |   -------------------------  | |  |
| | |                           |   |                              | |  |
| | |                           |   |   -------------------------  | |  |
| | +---------------------------+---+------------------------------+ |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 5 | Which of the following race and ethnicity categories do |  |  |
| | | 1 | you most closely identify with?  You can select more    |  |  |
| | | \ | than one.                                               |  |  |
| | | ) |                                                         |  |  |
| | |   | (Select all that apply.)                                |  |  |
| | |   |                                                         |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Hispanic    |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   White       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/i                                           |  |  |
| | |   | mage2.png){width="0.21875in"   African-American / Black |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Asian       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![]                                                   |  |  |
| | |   | (media/image2.png){width="0.21875in"   Pacific Islander |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.p                                    |  |  |
| | |   | ng){width="0.21875in"   American Indian / Alaska Native |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image2.png){width="0.21875in"   Other       |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ----------------------------------                    |  |  |
| | |   | ------- ----------------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 5 | How old are you?                                        |  |  |
| | | 2 |                                                         |  |  |
| | | \ |   ----------------------------------------------------  |  |  |
| | | ) |   \-- Choose one \--                                    |  |  |
| | |   |                                                         |  |  |
| | |   |   ----------------------------------------------------  |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 5 | What is your gender?                                    |  |  |
| | | 3 |                                                         |  |  |
| | | \ | (Select one.)                                           |  |  |
| | | ) |                                                         |  |  |
| | |   |   ------------------------                              |  |  |
| | |   | ----------------- ------------------------------------- |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Female      |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Male        |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |                                                         |  |  |
| | |   |   ![](media/image3.png){width="0.21875in"   Refused     |  |  |
| | |   |   height="0.21875in"}                                   |  |  |
| | |   |   ------------------------                              |  |  |
| | |   | ----------------- ------------------------------------- |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | +---+---------------------------------------------------------+  |  |
| | | 5 | Agency Name                                             |  |  |
| | | 4 |                                                         |  |  |
| | | \ |   ----------------------------------------------------  |  |  |
| | | ) |   \-- Choose one \--                                    |  |  |
| | |   |                                                         |  |  |
| | |   |   ----------------------------------------------------  |  |  |
| | +---+---------------------------------------------------------+  |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+