After your WIC visit, please take a few moments to answer these questions to help us better serve you and other WIC participants.

Question Title

* 1. What helped you keep today's appointment? (Mark all that apply) 

Question Title

* 2. If you have to miss appointments, why? (Mark all that apply)

Question Title

* 3. If all of these options were offered, how would you like to be reminded about your WIC appointments? (Mark all that apply) 

Question Title

* 4. What day(s) of the week would work best for yor WIC appointment? (Mark all that apply)

Question Title

* 5. What time(s) of day would work best for your WIC appointment? (Mark all that apply) 

Question Title

* 6. How did you learn about WIC?

Question Title

* 7. Based upon your time with WIC, how do you feel about the following?

  Yes Somewhat No N/A
The WIC clinic makes my family and me feel welcome.
The WIC Staff is friendly and listed to my concerns.
The right amount of time was spent for my WIC visit.
Other services I needed were offered during my appointment?
Did the clinic staff explain what foods WIC provides in a clear manner?
WIC foods support my food preferences.
WIC foods support my cultural preferences.
WIC foods support my religious needs.
WIC foods support my medical needs. 
I get all the WIC foods on my checks/coupons. 

Question Title

* 8. Check which foods you routinely do NOT buy with your WIC checks:

Question Title

* 9. ONLY FILL OUT:  If you are pregnant, breastfeeding or have a child 12 months or younger.  How do you feel about the following?

  Yes Somewhat No N/A
I felt WIC helped me with breastfeeding.
I felt WIC helped me even if I decided not to breastfeed.
I am comfortable breastfeeding at the WIC clinic.
The person who talked with me about breastfeeding was friendly.
WIC helped me with my breastfeeding goals.
I know about the extra food benefits for breastfeeding Moms.
The right amount of time was spent talking about breastfeeding. 

Question Title

* 10. What else would you like to share about your experience with the WIC program?

T