2010 Georgia WIC procedures manual & Georgia state plan [2010]

2010 GEORGIA WIC PROCEDURES MANUAL
& STATE PLAN
ga

GA WIC 2010 PROCEDURES MANUAL

Introduction

TABLE OF CONTENTS

Page

I.

Purpose/Mission .....................................................................................................IN-1

II.

Scope ..........................................................................................................................IN-1

III. References .................................................................................................................IN-1

IV. Prior Approval .........................................................................................................IN-1

V.

Policy/Action Memos .............................................................................................IN-2

VI. Sections ......................................................................................................................IN-2

A. Introduction (IN)................................................................................................IN-2

B. Certification (CT) ...............................................................................................IN-2

C. Rights and Obligations (RO) ............................................................................IN-3

D. Administrative (AD)..........................................................................................IN-4

E. Vendor (VM).......................................................................................................IN-5

F. Food Package (FP)..............................................................................................IN-5

G. Nutrition Education (NE) .................................................................................IN-6

H. Special Population (SP) .....................................................................................IN-6

I. Outreach (OR).....................................................................................................IN-6

J. Food Delivery (FD) ............................................................................................IN-7

K. Compliance Analysis (CA) ...............................................................................IN-7

L. Monitoring (MO)................................................................................................IN-8

M. Breastfeeding (BF) ..............................................................................................IN-8

N. Disaster Plan (DP) ..............................................................................................IN-8

O. WIC Procedures Manual Glossary ..................................................................IN-8

GA WIC 2010 PROCEDURES MANUAL

Introduction

VII. Administration .........................................................................................................IN-8 A. Food and Nutrition Services (FNS)/USDA ...................................................IN-8 B. State Agency .......................................................................................................IN-9
VIII. Addresses ..................................................................................................................IN-9 A. Local Agencies....................................................................................................IN-9 B. State Agency .....................................................................................................IN-16

GA WIC 2010 PROCEDURES MANUAL

Introduction

I. PURPOSE/MISSION
The purpose of the Georgia WIC Program Procedures Manual is to provide local agency staff with a guide to WIC Program operations. The information in this manual is to be used in the delivery of services to WIC Program applicants and participants in the State of Georgia.
The mission of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is to improve the health of low-income women, infants and children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating and referrals to health care. The mission of (WIC) is to provide policy direction and technical assistance to ensure continuity in program administration, operations, and compliance with program regulations, policies and procedures. The intent of the Grant-In-Aid is to support the efforts of local agencies to provide WIC programs services.
II. SCOPE
The information in the Georgia WIC Program Procedures Manual applies to all Department of Community Health (DCH) agencies, including district health units and non-DCH agencies that contract with DCH to administer and operate a WIC Program. The Georgia WIC Program encourages coordination of WIC and nutrition services with other health programs (e.g. maternal and child health, family planning, immunization), as well as health care providers in each local area (e.g. private physicians, hospitals, voluntary health organizations).
III. REFERENCES
This manual reflects State policies, USDA Regional instructions, and Federal regulations. It is strongly recommended that a copy of the WIC Program Federal Register be filed with the Procedures Manual for cross-referencing.
IV. PRIOR APPROVAL
Many items in this manual require prior approval before implementation or purchasing. All requests for approval must be submitted, in writing, sixty (60) days prior to the date approval is needed. Examples of such requests include local agency assessment/certification forms, purchasing of ADP equipment, etc.

IN-1

GA WIC 2010 PROCEDURES MANUAL

Introduction

V. POLICY/ACTION MEMOS
Georgia WIC Policy/Action memos, distributed throughout the year, reflect current policies in the Georgia WIC Program. Policy/Action memos must not be re-written by District and/or local Staff. These policies must be kept at the district and clinic levels, wherever there is a Procedures Manual. Policy/Action memos must be accessible to all staff that work with the WIC Program. During monthly/quarterly meetings held with WIC and non-WIC staff, Policy/Action memos and changes must be discussed to keep staff abreast of current procedures. Policy/Action memos must be made available to State WIC staff during on-site monitoring visits. Ninety (90) days prior to a program review, District/Local agency staff must not contact the Georgia WIC Program for a copy of Policy/Action memos. During the fourth quarter of each year, the Procedures Manual will be completely revised and reprinted and all Policy/Action memos from the year will be incorporated into the Georgia WIC Procedures Manual.

VI. SECTIONS
The Georgia WIC Program Procedures Manual is divided into sixteen (16) sections, which are described as follows:
A. Introduction (IN) Section includes: 1. Purpose 2. Scope 3. References 4. Prior Approval 5. Policy Memos 6. Sections 7. Administration 8. Addresses (Local and State)
B. Certification (CT) Section includes: 1. General 2. Eligibility Requirements 3. Initial Application 4. Processing Standards 5. Participant Identification
IN-2

GA WIC 2010 PROCEDURES MANUAL

Introduction

6. Georgia WIC Program Identification (ID) Card 7. Proxies 8. Income Eligibility 9. Nutritional Risk Determination 10. Nutrition Risk Criteria 11. Nutrition Risk Priority System 12. Changes Within a Valid Certification Period 13. Certification Periods 14. Infant Mid-Certifications Nutrition Assessment 15. WIC Assessment/Certification Form 16. Ineligibility Procedures (Notification Requirements) 17. Transfer of Certification 18. WIC Overseas Program 19. Correcting Official WIC Documents 20. Late Entry Correction on Health Records 21. Documentation Procedures 22. Certified Waiting List 23. System Information Management 24. Immunization Coverage Assessment 25. Complaint Procedures 26. Special Certification Conditions (Home Certifications) 27. Special Certification Conditions (Hospital Certifications) 28. Clinic Staff Ratio 29. PNSS Data Collection 30. WIC Interview Script
C. Rights and Obligations (RO) Section includes: 1. Rights and Obligations of WIC Applicants/Participants 2. Non-discrimination Clause 3. Public Notification 4. Civil Rights 5. Fair Hearing Procedures - Participants 6. Fair Hearing Procedures - Migrants 7. Administrative Appeals - Local Agency 8. Availability of Hearing Records 9. National Voter Registration Act 10. Pre-Approval/Pre-Award Review

IN-3

GA WIC 2010 PROCEDURES MANUAL

Introduction

D. Administrative (AD) Section includes: Section One Financial Management 1. Agreement with State Agency 2. Financial Procedures 3. Funding Requirement 4. Equipment Inventory 5. Retroactive Benefits and Reimbursements 6. Local Agency Collections
Section Two Statewide Cost Allocation Plan 1. Introduction to WIC Statewide Cost Allocation Plan 2. Basic Cost Principles/WIC Allowable Costs 3. Method for Charging the Cost of Wages and Salaries 4. Method for Charging the Salary and Non-Salary Cost

Section Three Program Administration 1. Retention of Records 2. WIC Acronym and Logo 3. Lobbying Restrictions 4. Confidentiality 5. E-Mail and Faxing Confidential Information 6. WIC Volunteers and Confidentiality 7. Health Insurance Portability and Accountability Act 8. Retroactive Benefits and Reimbursements 9. Mandatory No-Smoking Policy 10. Subpoenas 11. Search Warrants 12. Program Participation 13. Establishing New Clinics/Clinic changes 14. Clinic Closings 15. Damaged Formula Report 16. Reporting Systems Problems 17. Request for Financial and/or Statistical Data 18. Identification Cards and Food List Order 19. Client/Staff Ratio

IN-4

GA WIC 2010 PROCEDURES MANUAL

Introduction

20. Nutrition Services Director Job Description 21. Compliance Reviews 22. Medical Nutrition Therapy 23. Registered and/or Licensed Dietitian Credentialing Policy for DCH
Division of Public Health 24. Conflict of Interest 25. Renovations 26. Inter/Intra Agency Agreement 27. Patient Flow Analysis

E. Vendor (VN) Section includes: 28. Number and Distribution of Authorized Vendors 29. Vendor Applications Periods 30. Vendor Selection and Authorization 31. Peer Groups 32. Vendor Agreements 33. Vendor Training 34. High Risk Identification System 35. Prohibition Against Certain Vendors-Consolidated Appropriations Act 2005 36. Vendor Cost Containment 37. Routine Monitoring 38. Vendor Sanction System 39. Administrative Review 40. Coordination With Food Stamp Program 41. Staff Training in Vendor Management

F. Food Package (FP) Section includes: 42. Authorization of Foods 43. Prescribing Foods - General 44. Infants 45. Women, Children and Infants with Qualifying Medical Conditions 46. Children 1-5 years 47. Women

IN-5

GA WIC 2010 PROCEDURES MANUAL

Introduction

48. Homelessness, Migrancy, and Disaster Situation 49. Medical Documentation 50. Formula Distribution/Tracking Guidelines 51. Office of Nutrition Special Formula Orders 52. Emory Genetics

G. Nutrition Education (NE) Section includes: 53. Purpose 54. Definition 55. Goals 56. State Agency 57. Local Agency 58. Participant Nutrition Education 59. Participant Referrals to Other Agencies 60. Nutrition Education Materials

H. Special Population (SP) Section includes: 61. Introduction 62. Individuals Residing in Non-Traditional Housing or Institutions 63. Other Special Populations 64. Referral and Outreach to Special Populations

I. Outreach (OR) Section includes: 65. General 66. Methods of Outreach 67. Agencies to Contact for Outreach 68. Public Notification 69. Public Comments Period 70. Outreach During A Waiting List 71. Program Costs 72. Coordination/Integration of Services

IN-6

GA WIC 2010 PROCEDURES MANUAL

Introduction

J. Food Delivery (FD) Section includes: 73. General 74. Types of WIC Vouchers 75. Voucher Issuance - General 76. Vouchers Printed on Demand (VPOD Vouchers and Computer Printed Voucher) 77. Manual Vouchers (Blank and Standard) 78. VPOD Procedures 79. Mailing/Delivery of WIC Vouchers 80. Prorated Vouchers 81. Late Pick-up of Vouchers 82. Coordination of Health Services and Voucher Issuance 83. Lost, Stolen or Damaged Vouchers 84. Borrowed Vouchers 85. Critical Errors 86. Cumulative Unmatched Redemption Report (CUR) 87. Unmatched Redemption Report 88. Reconciliation of WIC Reports and Daily Program Operations
K. Compliance Analysis (CA): Section includes: 89. Introduction 90. Monitoring 91. Participant Abuse 92. Procedures for Repayment of WIC Funds 93. Guidelines for Investigating Employee Abuse 94. Procedures to Request an Employee Investigation 95. Vendor Compliance Investigation 96. Compliance Investigation Food Purchases 97. Disqualified Vendor/Participant Access 98. Investigation of Missing Vouchers/VOC Cards 99. Security of Issuance Material 100. Voucher Issuance Security

IN-7

GA WIC 2010 PROCEDURES MANUAL

Introduction

L. Monitoring (MO) Section Includes: 101. State Agency Monitoring 102. Quality Assurance Self-Reviews
M. Breastfeeding (BF) Section includes: 103. Introduction 104. Definitions 105. State Agency 106. Local Agency 107. Participant Education 108. Participant Referral 109. Breastfeeding Materials and Resources 110. Allowable Cost for the Promotion and Support of Breastfeeding 111. Documentation of Breastfeeding Rates
N. Disaster Plan (DP) Section includes: 112. Introduction 113. Policies 114. Assessing Impact of Disaster 115. Concept of Operation 116. Responsibilities 117. Resource Requirement 118. Types of Disaster 119. Division Mutual Aid Agreement 120. Department Disaster Plan
O. WIC Procedures Manual Glossary

VII. ADMINISTRATION A. Food and Nutrition Services (FNS)/USDA FNS/USDA administers the Program nationwide and provides grants to state health agencies.
IN-8

GA WIC 2010 PROCEDURES MANUAL

Introduction

B. State Agency
In Georgia, the Department of Community Health, Division of Public Health, administers the program and allocates funds to local agencies. Most local agencies are district health units, which are comprised of county health departments. Two (2) local agencies, Southside Medical Center, Inc. and Grady Health System contract with DCH to administer and operate the WIC Program.

VIII. ADDRESSES

A. Local Agencies

The following table lists all local agencies, their address, counties served, and the number of clinic sites.

DISTRICT/ADDRESS

COUNTIES SERVED

# OF WIC CLINIC SITES

District 1, Unit 1 (Rome)

Dade, Walker,

12

Catoosa, Polk,

C. Wade Sellers, M.D., M.P.H.

Chattooga, Gordon,

District Health Director

Floyd, Bartow,

Margaret Bean, BSN, M.S., R.N.

Paulding, Haralson

Program Manager

Rhonda Stephens R.D., L.D., CLC

District Nutrition Services Director

Northwest Georgia Health District

NW GA Regional Hospital

1305 Redmond Road

Rome, GA 30161

(706) 295-6661/(706) 295-6015

District 1, Unit 2 (Dalton)

Whitfield, Murray,

7

Gilmer, Fannin,

Harold W. Pitts, M.D.

Pickens, Cherokee

District Health Director

Louise Hambrick, MSN, MBA, RNCS, FNP

Program Manager

Karen Rutledge, RD, LD, CLC

Interim District Nutrition Services Director

Northwest Health District Office

100 W. Walnut Avenue

Suite #92

Dalton, GA 30720

(706) 272-2342/(706) 272-2223

IN-9

GA WIC 2010 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS
District 2 (Gainesville)
David Westfall, M.D., CPE District Health Director Edith Parsons, PhD, MEd Deputy Program Manger Charlene Thompson, L.D. District Nutrition Services Director DCH Health District 2 Office 1280 Athens Street Gainesville, GA 30507 (770) 535-5743/(770) 535-5958

COUNTIES SERVED

# OF WIC CLINIC SITES

Banks, Dawson,

14

Forsyth, Franklin,

Habersham, Hall,

Hart, Lumpkin,

Rabun, Towns,

Stephens, Union,

White

District 3, Unit 1 (Cobb)

Cobb, Douglas

8

John Kennedy, MD, MBA District Health Director Lisa Crossman, M.S. Director for Health Promotion and Prevention Barbara Stahnke, MS, RD District Nutrition Services Director Shenica H. King, R.D., L.D. Nutrition Manager Clinical Nutrition Manager Metro West Health District Office 1650 County Services Pkwy. Marietta, GA 30008 (770) 514-2325/ (770) 514-2419

District 3, Unit 2 (Fulton)

Fulton

11

Kimberly Turner, M.D., M.P.H. District Health Director (Acting) Elizabeth Pape, RD, LD District Nutrition Services Director Fulton County Health Department and Wellness 515 Fairburn Road Suite #350 Atlanta, GA 30331 (404) 505-6754/ (404 893-1899

IN-10

GA WIC 2010 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS
District 3, Unit 3 (Clayton)
Alpha Bryan, M.D. District Health Director Dianne Banister Program Manager Glenn Pryor, RD, LD District Nutrition Services Director Clayton County Health Department 1117 Battle Creek Road Jonesboro, GA 30236 (678) 610-7639/ (404) 603-4872
District 3, Unit 4 (Gwinnett)
Lloyd M. Hofer, M.D., M.P.H. District Health Director Connie Russell Program Director Diane Shelton, RD District Nutrition Services Director P.O. Box 897 2570 Riverside Parkway Lawrenceville, GA 30046 (770) 339-4260/ (770) 339 -2334 (678) 442-6865 ( ext. 188) /(678) 376-9062
District 3, Unit 5 (DeKalb)
Sandra Elizabeth Ford, M.D., MBA District Health Director Betty Neal, RN Programs Manager (404) 370-7373/ (404) 370-7379 Marsha Canning, L.D. District Nutrition Services Director 395 Glendale Road Scottdale, Georgia 30079 (770) 297-7204

COUNTIES SERVED

# OF WIC CLINIC SITES

Clayton

1

Gwinnett, Rockdale,

6

Newton

DeKalb

7

IN-11

GA WIC 2010 PROCEDURES MANUAL
DISTRICT/ADDRESS
District 4 (LaGrange)
Michael Brackett, M.D., F.A.A., F.P. District Health Director John G. Darden Program Manger Blanche Deloach, R.D., L.D. District Nutrition Services Director District 4 Public Health Office 122 Gordon Commercial Drive Suite A LaGrange, Georgia 30240 (706) 845-4035/(706) 845-4309
District 5, Unit 1 (Dublin)
Lawton Davis, M.D. District Health Director Bruce Evans, M.S. Program Manager Brent Gibbs, R.D., L.D. Nutrition Services Director South Central Health District Office 2121-B Bellevue Road Dublin, GA 31021 (478) 275-6545/ (478) 275-6575
District 5, Unit 2 (Macon)
David N. Harvey, M.D. District Health Director Roy Moore Program Manager Nancy Jeffery, RD., LD District Nutrition Services Director 5191 Columbus Road, Suite B Macon, Georgia 31206 (478) 471-5335/(478) 445-1139

Introduction

COUNTIES SERVED

# OF WIC CLINIC SITES

Fayette, Heard,

17

Henry, Butts, Carroll,

Coweta, Lamar, Pike,

Meriwether, Troup,

Spalding, Upson

Bleckley, Dodge,

12

Laurens,

Montgomery, Pulaski,

Telfair, Treutlen,

Wilcox, Wheeler,

Johnson

Hancock, Houston,

17

Jasper, Baldwin, Bibb,

Crawford, Jones,

Monroe, Peach,

Putnam, Twiggs,

Washington,

Wilkinson

IN-12

GA WIC 2010 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS
District 6 (Augusta)
Ketty M. Gonzales, M.D. District Health Director East Central Health District Office 1916 North Leg Road Augusta, GA 30909 (706) 667-4250/ (706) 667-4365 John Nolan Deputy Health Director Frances Wilkinson, M.S., R.D., L.D. District Nutrition Services Director East Central Health District Office 1916 North Leg Road Augusta, GA 30909 (706) 667-4287/ (706) 667-4667
District 7 (Columbus)
Zsolt Koppanyi, M.D., MPH., F.A.A.P. District Health Director J. Edward Saidla Program Manager Brenda Forman, RD, LD, District Nutrition Services Director West Central Health District Office 2100 Comer Avenue P.O. Box 2299 Columbus, GA 31902 (706) 321-6281/FAX (706) 321-6295
District 8, Unit 1 (Valdosta)
Lynne D. Feldman, M.D., M.P.H. District Health Director Elsie Napier Program Manager Janet McClure, R.D., L.D. District Nutrition Services Director P.O. Box 5147 Valdosta, GA 31603 312 N. Patterson Street Valdosta, GA 31601 (229) 333-5290/(229) 333-7822

COUNTIES SERVED

# OF WIC CLINIC SITES

Burke, Columbia,

20

Emanuel, Glascock,

Jefferson, Wilkes,

Warren, Jenkins,

Lincoln, McDuffie,

Richmond, Screven,

Taliaferro

Harris, Talbot, Dooly,

19

Quitman, Taylor,

Marion, Macon, Crisp,

Sumter, Clay, Schley,

Webster, Randolph,

Stewart, Muscogee,

Chattahoochee

Ben Hill, Berrien,

12

Brooks, Cook, Echols,

Irwin, Tift, Turner,

Lanier, Lowndes

IN-13

GA WIC 2010 PROCEDURES MANUAL
DISTRICT/ADDRESS
District 8, Unit 2 (Albany)
Jacqueline Grant, M.D. District Health Director Brenda Greene, RN,BSN,MPA Program Manager Susan Miller, RD., LD., CLC District Nutrition Services Director Southwest Health District Office 1306 S. Slappy Blvd. Suite G. Albany, GA 31701 (229) 430-4111/ (229) 430-3866
District 9, Unit 1 (Coastal)
W. Douglas Skelton, M.D. District Health Director Randy McCall Program Manager Tonya Scott, RD District Nutrition Services Director Coastal Health District Office 150 Scanton Connector Brunswick, GA 31525 (912) 262-2341/ (912) 262-2315 District 9, Unit 2 (Waycross)
Rosemarie Parks, M.D., M.P.H District Health Director Susan Horne, MPH., LD. Program Manager Heather Peebles, RD, LD District Nutrition Services Director
Southeast Health District 1115-B Church Street Waycross,GA 31501 (912) 285-6110/(912) 287-6521

Introduction

COUNTIES SERVED

# OF WIC CLINIC SITES

Baker, Lee, Calhoun,

16

Miller, Colquitt,

Mitchell, Decatur,

Seminole, Dougherty,

Terrell, Early,

Thomas, Grady,

Worth

Bryan

15

Camden

Chatham

Effingham

Glynn

Liberty

Long

McIntosh

Appling, Atkinson,

18

Bacon, Jeff Davis,

Brantley, Ware,

Bulloch, Candler,

Clinch, Charlton,

Evans, Coffee, Wayne,

Pierce, Toombs,

Tattnall

IN-14

GA WIC 2010 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS
District 10 (Athens)
Claude A. Burnett, M.D. District Health Director Louis Kudon, PhD. Program Manager Vicky Moody, M.P.H., L.D. Ann Sears, MED District Nutrition Services Director Northeast Health District WIC Office 189 Paradise Blvd Athens, GA 30607-3808 (706) 583-2859 / (706) 543-2034

COUNTIES SERVED

# OF WIC CLINIC SITES

Barrow, Clarke,

17

Elbert, Green, Jackson,

Madison, Morgan,

Oconee, Walton,

Oglethorpe

Southside Medical Center

Portions of Fulton and

3

Dekalb Counties

David Williams, M.D.

Director/CEO

Barbara Persaud, M.D.

Program Manager/Medical Director

Laverne Montgomery, M.A., R.D., L.D.

District Nutrition Services Director

Southside Medical Center

1039 Ridge Avenue, S.W.

Atlanta, Ga 30315

(404) 564-6784, Ext. 97

Grady Health System

ALL

5

Rondell Jaggers, Pharm.D. Vice President for Pharmacy & Drug Information Director of Nutrition Services Bernadine Joubert (Kathy Taylor (Acting) District Nutrition Services Director Grady Health System P. O. Box 26011 80 Jesse Hill Jr. Drive, SE Atlanta, GA 30303 (404) 616-5401/(404) 616-7657 Fax

IN-15

GA WIC 2010 PROCEDURES MANUAL

Introduction

B. State Agency
State Agency agrees: 1. For technical assistance regarding all areas, except nutrition-related
topics, contact the State WIC Office. 2. To allocate Nutrition Services Administration (NSA) funds to the Local
Agency for use in meeting reimbursed allowable WIC administrative, nutrition education, breastfeeding and client service expenses of the Local Agency. 3. To pay cost for food vouchers issued by the Local Agency and redeemed by participating authorized vendors for eligible participants. 4. To monitor and evaluate the Local Agency to insure maximum effectiveness and efficiency to provide technical assistance, consultation and training to improve performance. 5. To provide specific manuals, forms, and nutrition education material required for operation of the program. 6. To conduct independent verification and validation that local WIC data system modifications are performing as expected and/or to ensure system modifications are in place and are operating in accordance with federal and state program regulations and guidelines.
Georgia Department of Community Health
State WIC Program Two Peachtree Street, N.E. 10th Floor Atlanta, Georgia 30303 (404) 657-2900 Hotline 1-800-228-9173 FAX (404) 657-2910 or (404) 651-6728
For technical assistance regarding nutrition-related topics, contact the Office of Nutrition. Georgia Department of Community Health Division of Public Health Office of Nutrition Office of Maternal and Child Health Two Peachtree Street, N.E. 11th Floor Atlanta, Georgia 30303 (404) 657-2884 FAX (404) 657-2886

IN-16

GA WIC 2010 PROCEDURES MANUAL

Certification

TABLE OF CONTENTS
Page I. General.........................................................................................................................CT-1
II. Eligibility Requirements ...........................................................................................CT-1 A. Category ..........................................................................................................CT-2 B. Physical Presence ...........................................................................................CT-2 C. Residency ........................................................................................................CT-3 D. Income .............................................................................................................CT-5 E. Nutritional Risk..............................................................................................CT-5 F. Requirements to Copy Identification, Residency and Income Proof...................................................................................................CT-6
III. Initial Application ......................................................................................................CT-7
IV. Processing Standards.................................................................................................CT-9 A. Timeframes .....................................................................................................CT-9 B. Walk-in Clinics .............................................................................................CT-10 C. Request for Extension..................................................................................CT-10
V. Participant Identification ........................................................................................CT-10
VI. Georgia WIC Program Identification (ID) Card ..................................................CT-11 A. Required Data...............................................................................................CT-12 B. Participant Instructions ...............................................................................CT-13
VII. Proxies .......................................................................................................................CT-13 A. Reasons for Proxies......................................................................................CT-14 B. Authorization ...............................................................................................CT-14 C. Voucher Pick Up, Issuance, and Use.........................................................CT-14 D. Restrictions....................................................................................................CT-15 E. Participant Instructions ...............................................................................CT-15
VIII. Income Eligibility .....................................................................................................CT-15 A. Procedures.....................................................................................................CT-16

GA WIC 2010 PROCEDURES MANUAL

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B. Adjunctive (Automatic) Eligibility ............................................................CT-18 C. Computing Income ......................................................................................CT-20 D. Documented Proof of Income ....................................................................CT-33 E. Applicants with Zero (0) Income ...............................................................CT-34 F. Verification of Income .................................................................................CT-34 IX. Nutritional Risk Determination .............................................................................CT-35 A. Required Data...............................................................................................CT-36 B. Referral Data .................................................................................................CT-36 C. Medical Data.................................................................................................CT-37
X. Nutrition Risk Criteria ............................................................................................CT-39
XI. Nutrition Risk Priority System...............................................................................CT-40 A. General Priorities I -VI..............................................................................CT-40 B. Special Considerations ................................................................................CT-41 C. Specific...........................................................................................................CT-41 D. Assignment ...................................................................................................CT-42
XII. Changes within a Valid Certification Period ......................................................CT-42 A. Women Who Cease Breastfeeding ............................................................CT-42 B. Upgrading a Priority ...................................................................................CT-43
XIII. Certification Periods ................................................................................................CT-43
XIV. Infant Mid-Certification Nutrition Assessment ..................................................CT-43
XV. WIC Assessment/Certification Form ...................................................................CT-45 A. General...........................................................................................................CT-45 B. Completion....................................................................................................CT-46
XVI. Ineligibility Procedures (Notification Requirements) ........................................CT-58 A. Written Notification.....................................................................................CT-59 B. Completion of Notice of Termination/Ineligibility/Waiting List Form .......................................................................................................CT-60 C. Ineligibility File ............................................................................................CT-60

GA WIC 2010 PROCEDURES MANUAL

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XVII. Transfer of Certification ..........................................................................................CT-61 A. Clinic Staff .....................................................................................................CT-61 B. Out of State Transfer....................................................................................CT-62 C. In-State Transfer ...........................................................................................CT-63 D. Release of Information/Original Certification Form..............................CT-63 E. Two Methods for Transfer..........................................................................CT-65 F. Ordering VOC Cards...................................................................................CT-67 G. Inventories.....................................................................................................CT-67 H. Issuance .........................................................................................................CT-68 I. Security ..........................................................................................................CT-69 J. Lost/Stolen/Destroyed EVOC or VOC Cards ........................................CT-69
XVIII. WIC Overseas Program...........................................................................................CT-70 A. General...........................................................................................................CT-70 B. Impact on USDA's WIC Program..............................................................CT-70 C. New EVOC or VOC Card Requirements .................................................CT-71 D. Completion of the EVOC or VOC Card....................................................CT-72 E. Acceptance of WIC Overseas Program EVOC or VOC Cards ..............CT-72
XIX. Correcting Official WIC Documents .....................................................................CT-72
XX. Late Entry Correction of Health Records .............................................................CT-73
XXI. Documentation Procedures ....................................................................................CT-73
XXII. Certified Waiting List ..............................................................................................CT-73 A. Procedures for Maintaining a Waiting List ..............................................CT-74 B. Procedures for Removal from the Waiting List.......................................CT-74
XXIII. System Information Management .........................................................................CT-74
XXIV. Immunization Coverage Assessment ...................................................................CT-75
XXV. Complaint Procedures.............................................................................................CT-76 A. Procedures for Processing a Complaint or Incident ...............................CT-76

GA WIC 2010 PROCEDURES MANUAL

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B. How to File a Complaint (Flyer) ................................................................CT-76 XXVI. Special Certification Conditions (Home Visits)...................................................CT-77 XXVII. Special Certification Conditions (Hospital Certification) .................................CT-79 XXVIII. Clinic Staff Ratio ....................................................................................................CT-86 XXIX. PNSS Data Collection .............................................................................................CT-86 XXX. WIC Interview Script ..............................................................................................CT-86

Attachments: CT-1 WIC Assessment/Certification Form Prenatal Woman..................................CT-87 CT-2 WIC Assessment/Certification Form Post Partum Breastfeeding ................CT-89 CT-3 WIC Assessment/Certification Form Post Partum Non Breastfeeding........CT-92 CT-4 WIC Assessment/Certification Form Infants ...................................................CT-94 CT-5 WIC Assessment/Certification Form Children................................................CT-96 CT-6 FFY 2010 Nutrition Risk Criteria Handbook .......................................................CT-98 CT-7 Measuring Length..................................................................................................CT-226 CT-8 Equipment Maintenance .......................................................................................CT-227 CT-9 Instructions for Use of Prenatal Weight Gain Grid...........................................CT-229 CT-10 Prenatal Weight Grid for Normal Weight and Twins ......................................CT-230 CT-11 Prenatal Weight grid for Underweight and Overweight.................................CT-231 CT-12 Signed Statement of Income (English) ................................................................CT-232 CT-13 WIC Income Eligibility Guidelines......................................................................CT-233 CT-14 Notice of Termination/Ineligibility/Waiting List Form (English).................CT-234 CT-15 Notice of Termination/Ineligibility/Waiting List Form (Spanish) ................CT-235 CT-16 Paper Verification of Certification Card .............................................................CT-236

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CT-17 Electronic Verification of Certification (EVOC) Card .......................................CT-237 CT-18 VOC Card Report (Example)................................................................................CT-238 CT-19 VOC Card Inventory Log (Clinic) .......................................................................CT-239 CT-20 VOC Card Inventory Log (Local Agency)..........................................................CT-240 CT-21 VOC Card Agreement ...........................................................................................CT-241 CT-22 VOC Card Form .....................................................................................................CT-242 CT-23 Women, Infant and Children (WIC) Ordering Form........................................CT-243 CT-24 State/District/Clinic Transmittal Form..............................................................CT-244 CT-25 Medicaid Right From the Start.............................................................................CT-245 CT-26 THERE IS NO CHARGE (Flyer) ..........................................................................CT-246 CT-27 Verification of Residency and/or Income Form................................................CT-247 CT-28 No Proof Form........................................................................................................CT-248 CT-29 Family Plus Medicaid Card ..................................................................................CT-249 CT-30 Disclosure Statement Employees and Relatives.............................................CT-250 CT-31 Income Calculation Form......................................................................................CT-251 CT-32 Identification, Residency and Income Proof List (English)..............................CT-252 CT-33 Identification, Residency and Income Proof list (Spanish) ..............................CT-253 CT-34 Thirty (30) Day Certification/Termination Form..............................................CT-255 CT-35 Department of Defense WIC Overseas Program VOC Card...........................CT-256 CT-36 WIC Overseas Program Contacts ........................................................................CT-257 CT-37 Proof of Residency Form for Applicants with P.O. Box Address ...................CT-258 CT-38 Income Verification Letter ....................................................................................CT-259 CT-39 Incident/Complaint Form ...................................................................................CT-260 CT-40 How to File a Complaint (Flyer) ..........................................................................CT-261

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CT-41 Request for WIC Services Log ..............................................................................CT-262 CT-42 WIC Interview Script .............................................................................................CT-263 CT-43 Separation of Duties Log .......................................................................................CT-264 CT-44 Military Income Inclusions and Exclusions........................................................CT-265

GA WIC 2010 PROCEDURES MANUAL

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I. GENERAL
Certification is the process whereby an individual is evaluated to determine eligibility for the WIC Program. All persons wishing to participate in the Georgia WIC Program must have their eligibility determined except those persons transferring within a valid certification period with proper verification (Refer to XVII). If eligible funds are available, the individual will be enrolled in the program and will be issued supplemental food vouchers, when applicable. Supplemental food is defined as those WIC foods that promote health as indicated by relevant nutrition science, public health concerns, and cultural eating patterns containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants, and children. Participants shall be issued vouchers at the time they are notified of their eligibility. If the client is certified in the home, vouchers must be issued at that time. The person may continue to participate in the program until the end of the certification period or the end of categorical eligibility, whichever occurs first, as long as the person complies with program rules and regulations. If ineligible, the individual is properly notified (See Ineligibility Procedures CT-XVI).
Applicants who do not meet the income requirement for WIC eligibility may be referred to the area food pantries or other food assistance programs.
Local agencies are encouraged to perform WIC certifications and issue vouchers in coordination with other public health services. However, WIC applicants/ participants must not be required to participate in other programs in order to receive WIC benefits.
Note: WIC services must be provided to the applicant/participant at no cost. The "No Cost for Services" flyer must be placed in an area where it is immediately seen by applicants/participants. During program reviews, the "No Cost for WIC Services" flyer (Attachment CT-26) will be monitored for compliance by the review team.
II. ELIGIBILITY REQUIREMENTS
The local agency may not establish any eligibility criteria for program participation other than those established by the State agency.
To be eligible and certified for program participation, an individual must meet all of the following requirements:

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A. Category
To meet this eligibility requirement, an applicant must be: 1. A pregnant woman; OR 2. A postpartum, breastfeeding woman within twelve (12) months
of the end of a pregnancy; OR 3. A postpartum, non-breastfeeding woman within six (6) months
of the end of a pregnancy; OR 4. An infant up to one (1) year of age; OR 5. A child up to five (5) years of age.
* The end of a pregnancy is the date the pregnancy terminates (e.g. date of delivery, spontaneous miscarriage or elective abortion). When a participant no longer meets the definition of pregnant woman; breastfeeding woman; postpartum, non-breastfeeding woman; infant; or child, he/she becomes categorically ineligible for the program (See Ineligibility Procedures CT-XVI). Refer to A Women Who Ceases Breastfeeding (See Changes within a Valid Certification Period CT-XII.A.), for procedures regarding the breastfeeding woman who becomes categorically ineligible.
Proof of citizenship is not required for aliens, refugees, or immigrants to receive WIC benefits. The Georgia WIC Program is exempt from any restrictions in regard to aliens, refugees, and immigrants.
B. Physical Presence
All applicants (women, infants and children) must be physically present at each WIC Certification. If the applicant does not present themselves at the clinic/health department, the reason for the exception must be documented in the comment section of the certification form or progress notes. Below is a list of applicable exceptions:
1. Newborn infants who are born to a mother who was on WIC during her pregnancy or was eligible to participate but was not certified. The infant must be brought into the clinic prior to two (2) months of age to avoid termination. Medical or high risk condition may not be present.
2. Disabilities - The local agency must grant an exception to applicants who are qualified individuals with disabilities and are unable to be physically present at the WIC clinic because of their disabilities, or applicants whose parents or caretakers are

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individuals with disabilities that meet this standard. Examples of such situations include: a. A medical condition that necessitates the use of medical
equipment that is not easily transportable; b. A medical condition that requires confinement to bed rest;
and c. A serious illness that may be exacerbated by coming into
the WIC clinic.
3. Receiving Ongoing Health Care An infant or child who was present at his/her initial WIC certification and has documentation of ongoing health care from a health care provider (other than the local WIC agency) may be exempt from physical presence requirements by the local agency, if unreasonable barriers exist.
4. Working parents or caretakers The local agency may exempt an infant or child from the physical presence requirements: a. If the infant/child was present for his/her initial WIC certification, or b. If the infant/child was present at a WIC certification within the last year and determined eligible, or c. If the infant/child is under the care of working parents/guardian whose working status presents a barrier to bringing the infant/child into the WIC clinic.
The following people may determine if special considerations are required:
a. Doctor b. Nurse c. Nutritionist d. Physician Assistant e. Competent Professional Authority (CPA) f. WIC Coordinator or Designee
Physical presence is required unless a participant qualifies for an exemption as stated above. A child or an infant must accompany the parent/guardian or caretaker to the WIC clinic even with a Physician's Referral.
C. Residency
Applicants must reside within the jurisdiction of the State of Georgia.

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There is no requirement for length of residency. The applicant should apply for WIC benefits in the county in which he/she resides. However, if the applicant(s) routinely receives health care services at a clinic outside their county of residence, they may apply for and receive WIC benefits at the same clinic. Proof of residency must be provided at each certification. Written proof of residency must include the name and street address. Post Office (P.O.) boxes are not acceptable proof of residency. However, if that is all the applicant/participant has, the Proof of Residency Form for Applicants with a P.O. Box address (Attachment CT-37) must be completed by the applicant/participant. File the completed form in the applicant/participant's health record. Attachment CT-37 may be used for multiple certifications if the following applies:
1. No change in P.O. Box; and 2. Same physical address.
Residency shall be determined by presenting an item, from the list of acceptable proof of residency, established in the applicant's name (see list below). In cases of a minor applicant or applicants that reside with parents/guardians with no evidence of Presumptive Medicaid eligibility, the Verification of Residency and/or Income form (See Attachment CT27) accompanied with a bill from the parent/guardian must be presented to determine residency. Proof of residency must be documented on the WIC Certification Form by documenting the type of proof verified (i.e. Electric Bill). A date stamped copy of the proof of residency must be kept in the medical record. The information on the Letter of Household Income Form must be transferred to the WIC Assessment/Certification Form.
Acceptable proof of residency includes: 1. Electric bill 2. Gas bill 3. Telephone Service bill 4. Water bill 5. Cable TV bill 6. Rent Receipt 7. Health Record (not a bill) 8. Medicaid Swipe Machine/Medicaid Internet Site address only if
it appear on the screen 9. Other (must verify the name of the document viewed on the
Certification form)
If an applicant/participant presents proof of residency containing a different name, refer to the definition of family (CT-VIII. C. 3.).

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What about other special populations?
Homeless Individuals and Migrants - The Homeless and Migrant applicants may not be able to provide proof of residency and are not required to present proof to receive WIC benefits. However, the No Proof Form (Attachment CT-28) must be completed by the applicant.
Migrant Farm workers - Migrants farm workers are considered "residents" of the local agency service area in which they apply for program benefits. Migrants are not required to show proof of residency. They must complete the No Proof Form.
Military Personnel may vote and pay taxes in one state, but have one or more temporary duty stations in another state. Their temporary duty station is their residence for WIC purposes.
Homeless Individual refers to a woman, infant or child who lacks a regular or primary night time residence, or whose residence is: a temporary accommodation of not more than 365 days in the residence of another individual; a public or privately operated shelter designated as temporary living and/or sleeping accommodations (including a welfare hotel, shelter for domestic violence victims); an institution that provides temporary residence for individuals intended to be institutionalized.
D. Income
Applicants must have a gross family income at or below 185% of the Federal Poverty Level. All applicants/participants must present proof of income or adjunctive income eligibility. If proof of income does not exist, use the No Proof Form (Attachment CT-28)
E. Nutritional Risk
Applicants must have an identifiable nutritional risk, as determined through a nutritional risk assessment, to be eligible for benefits. If no nutritional risks are evident, applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are less than 4 months of age. Infants less than 4 months of age cannot use Risk Code 401 to establish their nutritional risk.

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F. Requirements to Copy Identification, Residency and Income Proofs
All local agencies must place a date stamped copy of the Identification, Residency and Income proofs used to determine eligibility in the applicant's medical record.
Copies of proofs to be placed in the records are:
x Proof of Identification for transfers, Thirty-Day adjustments, initial and subsequent certifications.
x Proof of Residency for transfers, Thirty-Day adjustments, initial and subsequent certifications.
x Proof of Income for Thirty-Day transfer only, Thirty-day adjustments, initial and subsequent certifications.
Exceptions of Proofs:
x There are two exceptions for not having to copy proof for the medical record. The two exceptions are listed below: 1. Medical Records in a Hospital do not have to be copied. 2. Medical Records in clinics do not have to be copied. Additionally, Medical Records may only be used as proof if the applicant does not have any other proof. Excessive use of Medical Records as proof will be monitored on Self Reviews and State Audits. Medical Records may not be used as a standard proof for daily operations.
Location of proofs:
x Copies of proofs must be placed behind the current certification documentation. The exception to this rule will be based on Standing District policy for the location of documents.
Copying Proofs:
x All three proofs may be copied on one sheet of paper.
Note: New proofs must be obtained for each proof of identification for transfer, Thirty-Day adjustments, initial and subsequent certifications. Additionally, all proof must be valid; no expired documents should be accepted. No proofs should be over two months old such as electric bills, ect. All proof must be date stamped to match the certification date.

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III. INITIAL APPLICATION
A. Initial contact date is defined as the date the individual first requests WIC benefits, orally or in writing. E-mail inquiries are not used for initial date. An individual's initial contact date will remain the same unless there is a break in enrollment. A break in enrollment is the period or lapse of time between a valid certification period and the subsequent certification.

B. The following items must be recorded when an individual first requests the clinic during office hours and specifically requests WIC benefits (orally or in writing) and benefits are not provided.
1. Applicant's Name and Address 2. Category (i.e. pregnant, postpartum, infant, child, migrant) 3. Initial Contact Date (date services were requested) 4. Appointment Date or Date Services Were Received 5. New Appointment Date (if changed) and Reason for the Change 6. Telephone Number
Each district/clinic may develop its own system for documenting items 16 as long as it is implemented in a consistent manner. Suggested methods of documentation include, but are not limited to, a personal visit log, the WIC Certification/Assessment Form (Attachments CT-1 thru CT-5) or an appointment book.
C. If the applicant does not reside within the jurisdiction of the state, ineligibility procedures will be followed (See Ineligibility Procedures CTXVI).
D. An income eligibility assessment should be made either prior to rendering WIC nutrition assessment services or as the first step in the clinic visit process. If the applicant is income eligible, he/she will be screened for nutritional risk eligibility or a clinic appointment will be given for a nutritional risk assessment. If the client is not eligible on the basis of income, the ineligibility procedures will be followed (See Ineligibility Procedures CT-XVI). Income eligibility is valid for in stream migrant farm workers and their families for a period of twelve (12) months. The income determination can occur either in the migrant's home base area before the migrant has entered the stream, or in an in stream area during the agricultural season.

E. Employees must never certify, recertify, or issue vouchers to family members or blood relatives (i.e. their children, spouse, cousins, other

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blood related persons or those persons related by marriage) nor other persons residing in the same household. In cases where an employee's family member(s) requests certification/recertification, another clinic or health department staff must process the application and notify the WIC Coordinator. If this is not possible, arrangements must be made to transfer this applicant/participant to the nearest WIC clinic. Arrangements can also be made to assign another Competent Professional Authority (CPA) to the original site on the scheduled visit day. Every attempt must be made to minimize hardship for the applicant/participant. Documentation must be noted in the client's record.
The Disclosure Statement (Attachment CT-30) must be completed annually by all clinic employees who performs WIC services to inform district staff of their family participation on the WIC Program. This form must be completed by the local agency and returned to the WIC Coordinator by September 30th of each year. A copy of this form must also remain in the Health Department for audit purposes. Procedures for completing the Disclosure Statement (Attachment CT-30): 1. Fill in the County where you work. 2. Complete your name and title. 3. Check YES or NO if you are a WIC participant. 4. Answer the question about whether you have any relative(s)
within your service delivery area participating on the WIC Program. 5. If yes, fill in the name, relationship and date of certification on this form. When reviewing the records of employees on the Georgia WIC Program, use the Record Review Form located in the Monitoring Section of the Procedure Manual.
Note: Staff must not take their own income, residency or identification information, certify or issue vouchers to themselves or family members.
F. Special provisions must be made for scheduling employed, rural and migrant participants. In the event normal working hours are not convenient, early morning, late evenings, and weekend clinics must be held or an appointment given to meet the needs of the applicants/participants. Clinics must make provisions to provide service for those applicants/participants that need to pick up vouchers during the lunch hours.
G. Each local agency shall attempt at least one contact for a pregnant woman

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who misses her first appointment to apply for participation in the program. In order to reschedule the appointment, the local agency must have on file an address and telephone number where the pregnant woman can be reached.
1. With Medical Record Documentation of the contact(s) must be noted in the client's record. Documentation must specify if the participant was contacted by phone or mailed an appointment. The staff must sign or initial their attempt.
2. No Medical Record If the client does not have a record, documentation is still required. It is up to the local agency to keep this documentation manually or in the computer and have it on file for the State to review. The documentation will consist of: a. The name of the client b. Appointment date. c. Date of 2nd appointment. d. Documentation if 2nd appointment was made by phone or mail. e. The initials of the staff member who made the appointment.
Note: Failure to maintain this documentation will result in a corrective action.

IV. PROCESSING STANDARDS
A. Timeframes
Processing standard timeframes begin when the applicant request program benefits (i.e. initial contact date). Every effort should be made to meet processing standards when an applicant request services. Pregnant and breastfeeding women, infants and members of migrant farm worker families must be notified of their eligibility or ineligibility within ten (10) calendar days of their initial contact date for program benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days of their initial contact date for program benefits. If a line is formed at any clinic site for WIC services, and the applicant/ participants cannot be seen that day; please provide each person who stood in line with an appointment prior to their leaving the clinic.

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A Request for WIC Services Log (Attachment CT-41) has been developed to document Processing Standards. If your District is already using a document, the state will review it. However, if your District does not have a log, this form must be used immediately.
B. Walk-in Clinics
Walk-in clinics are an excellent way to meet processing standards. The six (6) items collected at the time of the initial application (See CT-III.B) must be documented. A clinic that does not routinely schedule appointments shall schedule appointments for employed adult applicants/participants to apply or reapply for participation in the WIC Program for themselves or on behalf of others, to minimize the time these applicants/participants are absent from the workplace.
C. Request for Extension
On an annual basis the State agency may grant an extension of ten (10) to fifteen (15) days to local agencies experiencing difficulty in meeting processing standards. Those local agencies in need of an extension are required to submit a written request, including justification, to the State agency by October 1 of each year. Justifiable reasons for granting an extension include, but are not limited to:
1. Rural or satellite clinics unable to provide services more than twice per month.
2. Agencies with a high migrant participation population. 3. Agencies experiencing a continuous backlog in appointments
reflecting ongoing difficulty in scheduling clients for prenatal/well-child appointments.

V. PARTICIPANT IDENTIFICATION
General
Identification must be presented, checked and documented for both the applicant/ participant and parent/guardian/caretaker at initial and subsequent certification. The identification must be documented before issuing of benefits to an infant or child participant at certification. (For person picking up vouchers See Food Delivery Section). Clinic staff may not personally identify an applicant/participant even if they know their identity. Other records which clinic staff considers adequate to establish identity may be used if approved by the Georgia WIC Program
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Coordinator or designated CPA. Other records used for identification purposes that have been approved by the district, must be documented on the Certification Form.
Acceptable Documentation: 1. Immunization Record (Presented by applicant) 2. Health/Medical Record (Presented by the applicant, already exists in the clinic or the record if transferred.) 3. Birth Certificate/Confirmation of Birth Letter 4. State ID 5. Driver's License 6. Military ID 7. Work or School ID 8. Social Security Card 9. WIC ID (For Voucher Issuance Only) 10. Hospital ID Bracelets (Mother & Baby) 11. EVOC/VOC Card (with additional ID) 12. Other
For a categorical list of acceptable proofs of identification that must be used for women, infants or children see the Monitoring Section. Immigrants, Migrant Farm workers or individuals who have experienced theft, loss or disaster may not be able to provide an acceptable proof of identification. In limited and special situations the No-Proof form (Attachment CT-28) may be utilized and must be completed by the applicant. A police report maybe required for individuals claiming theft or loss.
Note: Only one (1) piece of identification is required per applicant.

VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD
General
During the certification appointment, a Georgia WIC Program Identification (ID) card (See the Food Delivery Section) must be completed and issued to any person who is enrolled in the Program. An ID card must never be issued to a proxy. In instances where more than one (1) family member has been certified, each name should be listed on the ID card rather than issuing each family member a separate card. The ID card may be used for four (4) certification periods. Clinic staff must be certain that the person is properly certified for the program before issuing an ID card.

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Effective January 2006, English and Spanish WIC ID cards will be mailed biannually to each district based on participant caseload/ID card distribution calculation.
The Georgia WIC ID card or another form of valid identification must be presented by the participant, parent, guardian or caretaker, each time vouchers are picked up at the clinic. A proxy must present a valid identification with the WIC ID card when picking up vouchers. If a participant, parent, guardian or caretaker does not possess, or has lost his/her ID card, other identification is acceptable as verification and a new WIC ID card issued. Valid examples are: Social Security Card, Birth Certificate, Driver's License, etc.
When identity is checked for the person picking up vouchers at issuance, it must be documented. Accept the same information used for certification, use the same codes and document as listed below:
1. Manual vouchers Document on the manual voucher copy under the date.
2. Voucher Printed on Demand (VPOD) Document on the receipt under User's ID.

A. Required Data
All items on the front must be completed, before issuing the ID Card.
FRONT: 1. Participant's name 2. WIC ID number 3. Date certification period expires 4. Participant/parent/guardian/spouse/alternate parent's
signature 5. Food Package # 6. Signature of proxy (ies), if the participant designates one:
a. Refer to Food Delivery Section if the participant/parent /guardian/caretaker or proxy is unable to write.
b. This may be accomplished by the participant/parent/ guardian/caretaker after he/she has left the clinic.
7. Signature of clinic WIC official 8. Date card was issued 9. The WIC Program Stamp must appear in the designated box.
It is recommended that all of the information on the back of the ID card also be completed.

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BACK: 1. Appointment information 2. Voucher pickup code 3. Voucher interval code 4. Comments when needed 5. Clinic identifying information 6. Clinic telephone number 7. Clinic fax number
B. Participant Instructions
Participants/parents/guardians/spouse/alternate parent must be instructed on the purpose and use of the ID card. The following is a guide to the information that should be given to the participant regarding the WIC ID Card. Whenever possible; the participant's proxy (ies) should be present during the explanation.
1. This ID card is to identify you as an authorized WIC participant when picking up and/or redeeming vouchers. You should keep vouchers with the ID card. You must have your ID card when picking up vouchers, at certifications or when redeeming vouchers at the grocery store. A proxy must have the ID card to pick up or redeem vouchers. Refer to the section below for more information regarding proxies.
2. Notify the clinic if the ID card is lost or stolen. 3. Explain the "Expiration Date" and when the participant will be
due for eligibility screening. 4. Explain shopping procedures (i.e., review allowable items,
importance of separating foods, etc.).

VII. PROXIES
General
1. A proxy is a person who acts on behalf of the participant. An authorized proxy may pick up and/or redeem vouchers and may bring a child in for subsequent certifications in restricted situations.
2. A person who is certified for the WIC Program and issued a Georgia WIC ID card may designate up to two (2) persons to act as a proxy.
3. A proxy should be a responsible person who the participant/

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parent/guardian/spouse/alternate parent trust and whenever possible, should be another person in the same household as the participant. 4. If a proxy picks up vouchers or brings a child in for subsequent certification, clinic staff must ensure that adequate measures are taken for the provision of nutrition education and health services to the participant. 5. Documentation of proxies must be recorded on the Georgia WIC ID card and on either of the following:
x Certification form x Computer x Tickler file system
A. Reasons for Proxies
Situations where proxies may participate in the subsequent certification of a child include: 1. Illness of the guardian 2. Imminent or recent childbirth 3. Guardian's inability to come to the clinic site during business
hours and 4. Other extenuating circumstances
B. Authorization
Proxies must be authorized by the participant or parent/guardian/spouse /alternate parent. When a proxy is designated, the participant or parent/guardian/spouse/caretaker must have the proxy sign his/her name in the designated space on the WIC ID card in their presence (refer to the Food Delivery Section if a proxy is unable to write).
The alternate parent/guardian/spouse should be listed in the health record whenever possible. Without this documentation, local agencies have no proof of legal responsibility and health services may be denied.
C. Voucher Pick Up, Issuance, and Use
In order to pick up WIC vouchers, the spouse/proxy must have the participant's WIC ID card with additional ID.
During issuance, the proxy will sign the voucher register, VPOD receipt or manual vouchers (refer to Food Delivery Section if a proxy is unable to

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write).
D. Restrictions
1. Age - A proxy must be at least sixteen (16) years old, unless prior approval is obtained from the District Nutrition Services Director or designated Competent Professional Authority (CPA). Approval must be documented in the participant's health record.
2. Staff State, District Health Department, and local staff, including volunteers working for the Local health department may not act as proxies for participants.
3. Vendors Vendors must not be used as a proxy.
E. Participant Instructions
When an individual is certified for the Georgia WIC Program, explanation of the following must be provided: proxy use and function, the importance of choosing responsible proxies, how to authorize a proxy, and the participant's responsibility for instructing proxies on the proper procedures of voucher redemption.
The proxy must have or be able to provide the following information in order to certify a child: 1. A statement of family size and documentation of income (or
Medicaid, food stamps), residency and ID must be signed and dated by the child's parent/guardian/spouse/alternate parent. A form for this purpose has been developed by the State (Attachment CT-12). Use of this form is required at each recertification. 2. Proxy's ID 3. WIC ID Card 4. Knowledge of the child's medical history and nutritional habits/normal nutritional intake.
Note: The proxy should have the same knowledge regarding the above as you would expect the parent to have.

VIII. INCOME ELIGIBILITY
To be eligible for the WIC Program, an applicant/participant must present proof of gross annual family income equal to or less than 185% of the Federal Poverty Level. Income is defined as gross cash income before deductions. Georgia WIC income

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guidelines are implemented simultaneously with the Medicaid program income guidelines.
Public Law 103-438, the Healthy Meals for Healthy Americans Act, provides new regulations for conducting the WIC Program income assessment/determination for pregnant women. According to this law, a pregnant woman who does not meet income eligibility requirements for the WIC program on the basis of her current family size shall be reassessed for eligibility based on a family size increased by one or the number of expected infant(s). In keeping with current policy, confirmation of multiple gestations must be received verbally or via a written diagnosis from a physician or acting health professional under standing orders of a physician and documented in the participant's health record. The change in policy applies to income determination of a pregnant woman and her children. For example, if a pregnant woman is counted as two on her first visit to the office, and the pregnant woman comes back to the clinic to place her child (ren) on the program, the pregnant woman and fetus will continue to be counted as two people in the family. The use/implementation of this policy must not conflict with cultural, personal or religious beliefs of the individuals.
A. Procedures
All local agencies must use the following procedures and criteria to determine income eligibility for all WIC Program applicants/participants.
1. Pre-screening by telephone - Pre-screening for income over the phone is a local agency/clinic option. However, the formal application for WIC begins when the applicant/participant visits the clinic. Income eligibility must be assessed at this time. This is considered the initial contact date.
2. Confidentiality/Privacy - Clinic personnel who interview applicants for the WIC Program must determine the family size and income eligibility with as much confidentiality and privacy as possible.
3. Determining Family Size/Income Eligibility - Family size must be determined first (See Income Eligibility CT-VIII). Then, the income for that family must be calculated and compared to the maximum income allowed for that family size (Attachment CT13). Income eligibility must be determined before nutritional risk eligibility. When determining the income of the WIC applicant, the Income Calculation Form must be completed (Attachment CT-31), if the applicant does not qualify for adjunctive or

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presumptive eligibility and if the applicant has more than one income to calculate. If only one income was reported place a check in the designated space behind the statement "check here if only one income reported".
Procedures for completing the Income Calculation Form:
All local agencies must complete the Income Calculation Form in the absence of a computer, if the applicant does not qualify for adjunctive eligibility and has more than one income to calculate. Income calculation may also be done in the computer system. Each system will be reviewed on a monitoring visit to determine compliance. When completing this form:
1. Write/type in the ID Number if applicable (the ID number is an eleven-digit number).
2. Write/type name of the WIC applicant.
3. Write/type the address of the WIC applicant.
4. Complete the Income Calculation by filling in the following: a) Date b) Relationship and name of the person whose income is being given. c) Income source (which is a two-digit alphabet, i.e., P.S. for pay stub). d) Dollar amount earned which can be weekly/bi-weekly, monthly/yearly.
5. Other Income Section: a) Complete the dollar amount earned by each family member. Circle if the amount earned is weekly/biweekly, monthly/yearly. b) Total the amount of all income earned. Circle if the amount earned is weekly/bi-weekly, monthly/yearly. c) Answer the question, "Is the applicant income eligible?" YES or NO? d) Transfer this total to the Certification Form. e) Have applicant read their Right and Obligations. f) Have the applicant sign this form. g) Signature & Date of staff accepting income

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B. Adjunctive (Automatic) Eligibility
"Adjunctive" or automatic income eligibility for WIC applicants/ participants is mandated for the following individuals: - Recipients of Food Stamps and members of a household
currently participating in Food Stamps. - Recipients of Temporary Assistance for Needy Families (TANF)
and family members. - Recipients of Medicaid or members of families in which a
pregnant woman or infant receives Medicaid. This includes Presumptively Eligible Medicaid Recipients.
When a prenatal woman or infant receives Medicaid other family member(s) may qualify:
1. If a pregnant mother qualifies for Medicaid and is on the WIC Program, her infant and children qualify for WIC (Income only).
2. If an infant qualifies for Medicaid, his/her pregnant, breastfeeding or postpartum/non-breastfeeding mother may be placed on the program using the infant's Medicaid number.
3. If a pregnant woman qualifies for Medicaid, other categorically eligible family member(s) income qualifies for the program.
4. A child on Medicaid can not income qualify his/her mother or a sibling.
When an applicant qualifies for adjunctive eligibility, document the Program for which the applicant is eligible.
Note: Persons who are adjunctively income eligible for WIC must also be categorically eligible and assessed at medical/nutritional risk to qualify for the program.
Acceptable Proof of Eligibility
The WIC applicant may present either of the following as acceptable proof of income eligibility.
1. Medicaid: The participant enrolled in Medicaid will be issued a Medicaid identification card. This card will contain the participant's name, identification number, date of issue and the

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primary care provider. Current eligibility may be verified by using the Medicaid web portal. Active status on the print out will indicate current Medicaid eligibility. If the participant's address appears on the print out, it may be used to verify residency.
A participant who is enrolled in Medicaid but does not have a card at the time of certification may have eligibility verified by keying the name and date of birth into the Medicaid Web portal. The Interactive Voice Response (IVR) may also be used to verify the eligibility status by dialing 770-570-3373 or 1-866-211-0950.
Infants are issued a Medicaid number at the time of birth. Should a Medicaid eligible infant comes to clinic for the first time without the Medicaid card; ask the mother if the hospital issued a temporary Multi Health Network (MHN) number for the infant. If the mother does not have one, the IVR can provide it. Place the twelve digit number in the field provided for Medicaid numbers.
2. PeachCare All PeachCare participants must be screened for WIC income eligibility.
3. Food Stamps: Must present a notification letter. A copy of the notification letter must be copied, date stamped and placed in the medical record.
Either the Food Stamp ID Card number or a copy of the actual card must be placed in the health record as appropriate documentation.
Electronic Benefit Transfer (EBT) Card: EBT cards are currently being used for the Food Stamps and Temporary Assistance for Needy Families (TANF) Programs. The EBT Card can not be used as proof of eligibility for the Food Stamp Program or TANF.
4. Temporary Assistance for Needy Families (TANF):
Must present a notification letter (with dates of eligibility). A copy of the Notification Letter must be date stamped and placed in the health records as appropriate documentation.

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C. Computing Income
1. Current vs. Annual In determining income, clinic staff must compare the income of the family during the past twelve (12) months as well as the family's current income to determine which indicator more accurately reflects the family's status. Current income is defined as income received by the household during the month prior to the application. This decision, whether to use current or annual income, should be made on a case by case basis.
2. Monthly income equals a. Weekly income x 4.3 b. Bi-weekly income (every 2 weeks) x 2.15 c. Semi-monthly income (twice a month) x 2
Annual income equals a. Weekly income x 52 b. Bi-weekly income (every 2 weeks) x 26 c. Semi-monthly income (twice a month) x 24
All income sources should be converted to monthly income and added to reach the total monthly income for the household. The factors listed below must be rounded off.
a. If paid a different amount every week, add the four paychecks for a given month and then divide by 4 (to get a weekly average) and then multiply by 4.3 to get a monthly average.
b. Annual income is divided by 12. c. A lump sum payment should be divided by 12 to estimate
a monthly income (i.e. Lottery winnings). d. Quarterly payments are divided by 3 to get a monthly
rate.
Converting to and calculating annual income: All income sources may be converted to annual income and added to reach the total annual income for the household. Actual amounts as documented should be used (not rounded).
a. Hourly: hourly rate x hours per week x 52 b. Daily: daily rate x 5 (or number of workdays per week) x
52

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c. Twice a month: Pay rate x 24 d. Every two weeks: pay rate x 26 e. Monthly: pay rate x 12 f. Quarterly: pay rate x 4 g. When using an Income Tax Form to determine Income:
Look for the Total Income line item on the income tax form. Use the dollar amount on this line and divide by twelve (12).
The number in the family will also be listed under exemptions. Total income should reflect current circumstances.
The Economic Stimulus Rebate: The economic stimulus rebate is a lump sum payment and it is to be excluded when calculating income for potential WIC families.
3. Definition of Family/Economic Unit
Family is defined as a group of related or non-related individuals who are living together as one economic unit. Families or individuals residing in a homeless facility or an institution shall be considered a separate economic unit.
a. Children Residing with Alternate Parent - A child is counted in the family size of the parent, guardian or alternate parent with whom the child lives, with the exception of the foster child [See b]. For example, an abandoned child being cared for by a grandparent would be counted in the family size/household of the grandparent.
b. Foster Child - If the child is a foster child living with a family but remains the legal responsibility of a welfare agency or other agency, the child is considered a family of one (1). The payments made by the welfare agency or any other source for the care of that child is considered to be the income of that foster child.
c. Adopted Child - If a child lives with a family who has accepted legal responsibility, the child is counted in the family size of the family with whom he/she resides.
d. Joint Custody - A child who resides in more than one

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home as a result of a joint custody situation shall be considered part of the household of the guardian who is applying on behalf of the child.
e. Pregnant Women - A pregnant woman who does not meet income eligibility requirements for the Georgia WIC program on the basis of her current family size shall be reassessed for eligibility based on a family size increased by one or the number of expected infant(s).
f. Absent Spouse (excluding military families) - A household where the spouse is away and maintains a separate residence due to job related assignments shall be considered a separate economic unit without the inclusion of the spouse. Only income received by the household would be used to determine eligibility.
g. Students (1) College students who maintain a separate residence at school but who are supported by parents/guardians must be counted in the household of the parent/guardian. Students who maintain a separate residence and are self-supported must be counted as a separate household. Any regular cash supplements received from parents or guardians must be included in the student's total income. (2) If a student receives financial assistance from any program funded under Title IV (e.g. the Pell Grant, Supplemental Educational Opportunity Grant, Byrd Scholarship, Student Incentive Grant, National Direct Student Loan, PLUS, (College Work Study, etc.) the following guidelines must be followed: (3) The portion of federally-funded student aid that is used by the student for books, materials, tuition, fees, supplies and transportation will not be counted as income. Any portion of the aid that is used for room and board or dependent care costs will be counted as income.
h. Aliens/Foreign Students - It is legal for an alien/foreign student and his or her family to receive WIC benefits. Neither WIC authorizing legislation nor the WIC regulations require citizenship or make aliens categorically ineligible for the Georgia WIC Program.

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State and local agencies do not have the authority to exclude aliens solely on the basis of their alien status.
i. Military Families (1) Military personnel serving overseas or assigned to a military base are considered to be members of the family and their income should be included when determining family income. (2) If children are in the temporary care of others while their parent is assigned elsewhere or if the child (ren) and one parent temporarily move in with friends or relatives, choose one of the following options: (a) Count absent parents and exclude current caregivers. (b) Count children as a separate economic unit. The children are considered as having their own source of income (e.g., child allotments). When using this method, districts must decide whether the income is adequate to sustain the children. If the children's income allotments are not adequate, then option 1 or 3 should be used. (c) Count children as members of the caregiver's household. Determine family size based on the family child(ren) is/are living with. Include the children in the family size.
When taking income for the military employee, the pay stub for the military is called the Leave and Earning Statement (LES). Therefore, when an applicant is in the military:
1. Review the Leave and Earning Statement (LES) and find the amount received.
2. Add all applicable income inclusions (for a complete list see (Attachment CT-44) x Career Sea Pay x HFP (Hazardous Fire Pay)
3. Subtract all applicable income exclusions (for a complete list see (Attachment CT-44) x BAH (Basic Allowance Housing) x BAQ (Basic Allowance Quarters) if any apply x LQA (Living Quarters Allowance) x VHA (Variable Housing Allowance) x OCONUS COLA (Overseas Continental United

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States Cost of Living Allowance) x FSH (Family Separate Housing) 4. If the household appears to be over-income because the LES includes pay for any of the following, try to get a history to determine annual income: x Hazardous or foreign duty x Back pay or combat pay x Family separation x Clothing allowance
EXAMPLE: Peter, Florence and their children Charles and Todd live off base. They receive $2,490 per month, which includes a Living Quarter Allowance (LQA).
$2,490 Monthly amount $350 LQA
$2,140 per month for four (4) people
The LES contains: Individual's Name and Social Security Number Individual's rank Years of service Base Pay - dollar amount they receive Separate Rations (money for food) - dollar amount they receive BAH (Basic Allowance Housing) - dollar amount received BAQ - dollar amount they receive Basic Allowance Quarters BASD (Basic Active Service Date) - when they started in the Army ETS (Expiration of Term) - when their enrollment is completed and allotments are paid out.
j. Children Not Residing in the Household (excluding military families as outlined above) - Children not residing in the household to whom child support is paid as a result of divorce, may not be considered part of the WIC applicant's family. A WIC applicant may count in his/her family size, a child family member who resides in a school or institution if the child's support is paid for by the WIC applicant's family.

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k. Verification of Residency and/or Income Form - (Attachment CT27) The verification form is to be given to any potential applicant to assist them in collecting necessary documentation from other members of the family (economic unit) to determine income eligibility under the program. Clinics are encouraged to conduct Presumptive Medicaid Eligibility prior to issuing the Verification of Residency and /or Income form to any potential applicant who does not qualify.
Procedures for Completing the Verification of Residency and/or Income: (1) Write in the name(s) of the WIC applicant(s) along with
the address that is given. (2) Sign your name at the bottom portion of this form along
with date given to the WIC participant. (3) Complete or fill in the date that the form must be
delivered back to the clinic. (4) Once the form is received, write in the date received and
have the person who received it, sign the letter.
l. Migrants Income for migrants must be taken annually. Migrants will not be required to show proof of income; however, they must give their income verbally and the No Proof Form, (Attachment CT-28), must be signed. When the No Proof Form is completed, it becomes documented proof of income for that certification period and must be placed in the applicants' health record. Limit use of the No Proof Form to applicants who are in a situation unlikely to yield written documentation, such as: 1. Fire 2. Theft 3. Disaster 4. Migrants 5. Homeless 6. Employer who refuses to write a letter for employee when employee is paid in cash (day workers, domestic, etc) 7. Applicants whose spouse or partner refuses to give income information.
m. No Proof Form

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The No Proof Form is to be used when the applicant can not provide proof of ID, residency or income. If used, a detailed summary must be written by the applicant or adult applying on behalf of an infant/child applicant, as to the reason for not having this documentation (Attachment CT- 28) and must be filed in the health record.
The applicant or adult applying in behalf of an infant/child applicant, must self-declare income and family size, and write and sign a statement explaining why they are unable to obtain proof of family income. Do not accept an incomplete No Proof Form. Do not certify and issue benefits to an applicant who self-declares an income for family size that exceeds the WIC income guidelines.
Clinics are required to maintain a No Proof file. The No Proof file must contain a copy of the completed No Proof Form or a list of the participants. This file will be monitored for compliance by the review team.
n. Temporary Thirty (30) Day Certification This policy applies to clients who meet all other eligibility requirements do have proof of identity, income and/or residency and fail to bring it to the clinic for the certification visit. The Identification, Residency and Income Proof List (Attachments CT-32 and 33) should be routinely given to the client to clearly communicate the kinds of information they will need to bring for certification visits. Clinic procedures for issuing thirty (30) day certification are as follows (Attachment CT-34):
1. Procedures for Thirty (30) Days Certification When an applicant/participant arrives in the clinic without proof of residency, income or identification: (a) Place the applicant on the program using the Thirty (30) Day rule. (b) Proof that is not available on site must be entered as "NO" in the appropriate field on the computer. (c) Complete the Thirty (30) Day form. Give the client the original copy and place copies of the form in the Medical Record and the Thirty (30) Day file.

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(d) The computer system will update for the Thirty-Day eligibility. When a month has 28-31 days, the system must be fixed to accommodate the number of days per month. If your District is using hand written forms, your District must use the same procedures located in your District Computer System for calculating days.
2. Procedures when applicant/participant brings back required proof: If the participant returns with proof of residency, income or identification prior to the thirty (30) day period, generate and submit an updated Turn Around Document (TAD) to include the new information. The "up ____" has been added as a reminder to update the information on the hard copy of the Certification Form only once the participant returns to the clinic with the required information. The "up: ______" is found in the following sections of the Certification Form: x Proof of Residency x Current ID x Gross Income x Source of income code x Staff initials x Date Utilize the "up____" field as follows: (a) Update your computer system and submit an updated TAD. (b) When one or more of the fields are updated, the staff must initial and date the back of the form (hard copy only). (c) When income is updated, the amount and source must be updated. (d) The applicant/participant must return with the information. A proxy may not provide the necessary documentation to complete the Thirty (30) Day Certification process.
3. Procedures when applicant/participant fails to bring back proof: If the participant fails to return within thirty (30) days, the clinic must terminate the participant using the term code "L" (Failure to return with proof on thirty (30) day

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certification). Covansys will automatically terminate the participants if an update is not received. A Termination Report is generated and the terminations must be entered into the computer system.
(a) Reversing Terminations: If the applicant returns after the thirty (30) day grace period a reversal can be made for any participant in a valid certification period. The updated information must be entered in the term reversal Electronic Turn Around Document (ETAD).
(b) Procedure for Participant Transfers 1. When a participant transfers to another district, the receiving clinic must call the original clinic to determine the client's thirty (30) day status.
2. Vouchers must never be issued if the participant has not brought back the necessary information.
3. Procedures when applicant/participant is overincome. (a) document on the Thirty-Day form that participant is terminated from the program (b) staff must sign and date the Thirty-Day file copy and medical record (c) copies must be made and placed in medical record (income proof) (d) participant is terminated in the computer system
o. Hospital Certification If the local agency has a Memorandum of Agreement (MOA) or a completed Consent to Obtain Information form, document on the Certification Form that the hospital health record was the source viewed for identification and residency.
If the hospital record has recorded a Medicaid number, document on the Certification Form that the hospital health record was the source viewed for income.
p. Applicant Earning Cash Income with No Documentation There may be WIC applicants that have cash jobs with no

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documentation of their income. Ask them to complete the No Proof Form (Attachment CT- 28) indicating what their income is. Ask for documentation first.
q. Zero Income Applicants Complete applicable questions on back of assessment form. See Income Eligibility Applicants with Zero (0) Income (CT-VIII. E.).
1. Income Inclusions a. Monetary compensation for services, including wages, salary, commissions, or fees b. Net income from farm and non-farm self employment c. Social Security benefits and/or Supplemental Security Income (SSI) d. Dividends or interest on savings or bonds, income from estates or trusts, or net rental income e. Public assistance or welfare payments f. Unemployment compensation g. Government civilian employee or military retirement, pensions, or veterans' payments h. Private pensions or annuities i. Alimony or child support payments j. Regular contributions from persons not living in the household k. Basic Allowance for Subsistence (BAS) is cash payment added to base pay and is counted as part of all cash income for military families l. Net royalties m. Other cash income. This includes, but is not limited to, cash amounts received or withdrawn from any source including savings, investments, trust accounts, and other resources which are available to the family (e.g. money from friends and relatives).
2. Income Exclusions a. The value of in-kind housing and other in-kind benefits. An in-kind benefit is anything of value, which is not provided in the form of cash. b. Income or benefits received under any federal program, which are excluded from consideration as income by any legislative prohibition. These

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include, but are not limited to: (1) National School Lunch Act and the School
Breakfast Program (2) The Food Stamp Act of 1977 (3) Job Training Partnership Act (4) Home Energy Assistance Act of 1980 (5) National Older Americans Volunteer Program (6) Domestic Volunteer Service Act of 1973
(VISTA, Foster Grandparents, Retired Senior Volunteers Program, Senior Companions Program) (7) Child Nutrition Act of 1966 (8) Small Business Act (9) Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970 (10) Military Housing - BAQ (11) Title IV Student Financial Assistance.
c. Bank loans, other payments or benefits provided under certain federal programs or acts to be excluded may be found in the Federal Regulations governing WIC 7 CFR Part 246.7(d)(2)(iv).
d. Child care benefits provided under grant programs to states shall not be treated as income in federal programs such as WIC. Childcare benefits provided under section 402 (g)(1)(E) of the Social Security Act, At-Risk Child Care Programs, and Child Care and the Development Block Grant Programs in Georgia are excluded from the WIC income eligibility process.
e. Non-payment of child care benefits is not considered income. Benefits received in the form of cash or any other instrument that can be converted into cash may be considered income in the WIC income eligibility process. For WIC purposes, current program policy regarding any cash available to a family is applied.
3. Unemployment - Applicants from families with adult members who are unemployed shall be eligible based on income during the period of unemployment if the loss of

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income causes the current rate of income to be less than the income guidelines. Persons who are on leave that they requested themselves (e.g. maternity leave or a teacher not being paid during the summer) are not considered unemployed. In these instances, it may be more appropriate to use annual income to determine eligibility. If a woman is on extended maternity leave [greater than six (6) months], it may be more appropriate to use current income to determine eligibility.
4. Self-Employment - In families where adult members are self-employed, they may not know their net income. To calculate net income, use the most current income tax statement or on-going records and the following guidelines:
Net income for self-employment - is figured by subtracting operating expenses from gross receipts. Gross receipts include the total value of goods sold or service rendered by the business. Operating expenses include, but are not limited to: the cost of goods purchased; rent; heat; utilities; depreciation; wages and salaries paid; and business taxes (not personal federal, state, or local income taxes). The value of salable service and merchandise used by the family of self-employed persons is not to be included as an operating expense.
Net income for self-employed farmers - is figured by subtracting the farmer's operating expenses from the gross receipts. Gross receipts include, but are not limited to, the value of all products sold; money received from the rental of farm land, buildings or equipment to others; and incidental receipts from the sale of items such as wood, sand, or gravel. A farmer's operating expenses include, but are not limited to: the cost of feed, fertilizer, seed and other farming supplies; cash wages paid to farmhands; depreciation; cash rent; interest on farm mortgages; farm building repairs; and farm taxes (but not state and federal income taxes). The value of fuel, food, or other farm products consumed by the family is not included as an operating expense.
Note: For farm and non-farm self-employed persons, documentation of depreciation must be obtained

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before accepting such charges as operating expenses. Either federal or state income tax forms for the most recent tax year would provide the most reliable documentation of these amounts. In a household where there are wage earners and self-employed members, the wage earner's income may not be reduced by the business losses of the self-employed member. If the self-employed person's income is negative it should be listed as zero (0).
5. Hardship Conditions - Hardship conditions have been calculated in the Income Poverty Guidelines Chart. Hardship conditions are not to be considered when determining income.
6. Lump Sum Payments - Lump sum payments may be classified in two ways, either as reimbursement or new money.
Reimbursement payment(s) represents money received for loss of assets or injuries to real or personal property. Reimbursement lump sum payment(s) should not be counted as income for WIC eligibility purposes.
Examples include but are not limited to insurance reimbursement, payment on specified household expenses or medical expenses.
New Money is money received as gifts, inheritances, lottery winnings, workman's compensation for lost wages, or severance pay. Lump sum payments that represent new money intended to be used, as income should be considered as "Other Cash Income".
The lump sum payment must not be counted for one month of current income. Rather, the lump sum payment should be counted as annual income, or be divided by 12 to estimate a monthly income.
Some lump sum payments may not be easily classified into either of the two categories, reimbursement or new money; but may represent both. In such instances treat

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the lump sum payment in a way that most accurately reflects the economic situation of the household. Examples of such payment include legal or medical settlements that provide reimbursement for lost property and medical expenses, as well as compensation for physical or mental injury.
7. WIC Income Eligibility for Furloughed Federal Employees In determining income eligibility of categorically eligible persons affected by the federal shutdown(s), state and local agencies should use the same policies and procedures normally used to assess the income eligibility of a person experiencing a temporary loss of income such as temporarily laid-off or striking workers. Current income should be used to determine eligibility. Assuming that Federal shutdown(s) are temporary, local agencies should continue to provide benefits for the duration of the furlough. There is no federal policy, which requires the value of benefits to be paid back in such circumstances.
8. Incarcerated Parent/Guardian Children residing with a caretaker are counted in the family size of the caretaker with whom they live. Ideally legal custody is required. However, a note from the parent giving permission to the caretaker (i.e. grandmother) is acceptable and must be placed in the health record.
D. Documented Proof of Income
The Georgia WIC income screening policy requires income information from all applicants.
When requesting proof of income, you MUST ask for one of the following: 1. Pay stubs for all people in your household who work or who
receive an income from any source. Some pay stubs will not have a name but will have a Social Security Number. Ask for the Social Security Card. 2. A statement from employers for all people in your household. Attach non-letterhead statements from employers to the No Proof Form and file in the health record.

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3. Current tax return (W-2 or 1040). 4. On-going financial records (for self-employed only). 5. Unemployment Notice. 6. Other (See List of Income Inclusions).
For additional sources of income, see Income Inclusions (VIII.C.3.Q.1.).
E. Applicants with Zero (0) Income
When an applicant declares that they have no income (zero) except applicants that adjunctively income qualify, the following question must be asked and documented on the back of the certification form (under source of income):
Question: How do you obtain food, shelter, clothing and medical care? Document the answer on the Certification Form. Check "Yes" the client is income eligible. This does not apply to applicants with adjunctive income eligibility documents.
Record zero as the current income amount and "ZI" (zero income as income source).
F. Verification of Income
"Verification" means a process whereby the information presented, such as a pay stub, is validated through an external source other than the applicant. Such external sources include employer verification of wages, local public assistance office verification, etc.
Verification is required for questionable cases such as:
1. The person taking the income suspects that the income is incorrect.
2. A complaint is received alleging that a participant is not income eligible. An anonymous complaint must be handled in the same manner as any other complaint.
3. A conflict of information is found between Georgia WIC Program income data and income data provided from other programs. When income is verified, the income at the time of certification, rather than the current income, must be verified.

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Based on the three (3) reasons above, clinic staff may also request that the participant, parent, guardian or alternate parent bring proof of income back to the clinic. In the event clinic staff request proof, from the participant, parent, guardian or caretaker the Income Verification Letter (Attachment CT-38) may be used.
Failure of the participant, parent, guardian or caretaker to return to the clinic within thirty (30) days with proper documentation would result in the following:
1. Termination from the program. 2. Re-payment to the WIC Program for vouchers issued over
$100.00.
Note: Information concerning payment to the Georgia WIC Program can be found in the Compliance Analysis Section of the Procedures Manual.

IX. NUTRITIONAL RISK DETERMINATION
To be eligible for the WIC benefits, an applicant/participant must have an identifiable nutritional risk, as determined through a nutritional risk assessment. If no nutritional risks are evident, applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are less than 4 months of age. Nutritional risk is identified through the assessment of required medical data (length/height, weight, hematocrit/hemoglobin), nutritional practices, and the individual's medical history. The data are evaluated by a Competent Professional Authority (CPA) on staff at the clinic. A CPA is defined as a nutritionist, registered dietitian, registered nurse, licensed practical nurse, physician, or physician's assistant that has been trained by the State or local agency.
WIC applicants for WIC benefits may not under any circumstances be charged for services or tests (i.e. blood work, anthropometric measurements, etc.) which are used to determine program eligibility. If the local agency is unable to perform the prescribed tests on site, and if the applicant receives medical care from an outside provider, appropriate arrangements should be made to accept referral data from outside sources. Local clinics unable to perform required tests to assess program eligibility may be suspended by the Georgia WIC Program. The applicant cannot be required to obtain such data at their own expense.

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A. Required Data
1. Women - Attachments CT-1, CT-2, and CT-3 lists the required assessment data and documentation requirements for all women, by category. This data must be collected and documented for each assessment. Required medical data used to determine the eligibility of pregnant women must be taken during the current pregnancy. Proof of pregnancy is not required as a condition of eligibility for the Georgia WIC Program. However, if it is not physically apparent that the applicant is pregnant and if clinic staff has reason to believe that the applicant is not pregnant (i.e., a complaint is received alleging that a participant is not pregnant), the local agency may request proof of pregnancy after the initial certification. In this case, the participant can be given up to sixty (60) days to submit proof of pregnancy. If proof of pregnancy documentation is not provided as requested, the local agency may terminate the woman's WIC participation in the middle of a certification period. Postpartum women must have their required medical data taken after the termination of their pregnancy.
2. Infants - Attachment CT-4 lists required assessment data and documentation requirements for all infants by age. This data must be collected and documented for each assessment.
3. Children - Attachment CT-5 lists the required assessment data and documentation requirements for all children. This data must be collected and documented for each assessment. All required medical data used to determine nutritional risk must be reflective of the applicant's status at the time of certification.
B. Referral Data
Identification of nutritional risk can be based on referral data submitted by a CPA or health care provider not on staff at the clinic. Referral data must then be evaluated by a CPA on staff at the clinic. Local agencies should make authorized referral forms available to area health care providers in order to facilitate entry into the WIC Program and the certification process. Local agencies must accept the Georgia WIC Referral Form and Medical Documentation for Special Food Substitutions (Form #2, Attachment FP-39 in the Food Package Section), and may not develop their own referral form.

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Local agencies must accept referral forms from a private provider, provided that the entire minimum required referral data/information has been completed properly, as described below. The data/information must be documented on official letterhead.
All private provider referral forms must contain, at a minimum, the following information:
I. Demographic Data a. Applicant's First and Last Name b. Applicant's Date of Birth
II. Required Medical Data, as appropriate a. Length/Height b. Weight c. Hematocrit/Hemoglobin d. Date(s) measurements were taken
III. Referral Agency Information a. Original signature and title of health care provider b. Date the referral was completed c. Agency address d. Agency telephone and fax numbers
As a part of outreach efforts, local agencies may provide area health care providers with a current listing of nutritional risk criteria along with definitions and documentation requirements for the risk criteria.
C. Medical Data
Medical data required for certification includes anthropometric (length/height and weight) and hematological (hemoglobin/hematocrit) measurements.
1. The Medical Data Date documented on the WIC Assessment/Certification form must be the same as the date that the anthropometric data were taken. Anthropometric data required for certification (length/height and weight), may precede the date of certification by up to sixty (60) days. Required medical data that are greater than sixty (60) days old cannot be used to assess WIC eligibility. The sixty (60) day limit applies to the anthropometric data (length/height and weight) even if the applicant/participant's eligibility is based on other criteria.

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2. The Hematological Data Date documented on the WIC Assessment/Certification form must be the same as the date the hematological data were taken. Hematological data required for certification (hemoglobin/ hematocrit) may precede the date of certification by up to ninety (90) days. Required hematological data that are greater than ninety (90) days old cannot be used to assess WIC eligibility. The ninety (90) day limit applies to the required hematological data even if the applicant/participant eligibility is based on other criteria.
The Georgia WIC Program has elected to use special codes to be entered into the hematological data field when hemoglobin is not determined. Please use the following codes, based on the computer systems in your districts: a. Mitchell & McCormick (M&M): 88.8 b. Athens System: 88.8 c. Dekalb System: 88.8 d. Aegis: 88.8
Covansys is set up to accept these values to indicate that no blood work has been performed for any reason, and will not send this data to the Centers for Disease Control and Prevention (CDC).
Blood work should not be performed on infants younger than 9 months of age, unless there is a medical reason.
In most cases, infants will have blood work performed around 12 months of age (infant status blood work) and then 6 months later (child status blood work). If the child's blood work is normal, blood work does not have to be performed for a year. If the blood work is abnormal, follow one of the two following procedures:
a. For infants and children receiving their health care through the health department, follow the protocol for treatment of low hemoglobin. Once the hemoglobin becomes normal during a certification assessment, it does not have to be assessed for another year.
b. For infants and children receiving health care from a private provider, refer the participants with low hemoglobin values to their providers. At the next certification visit repeat the hemoglobin test or enter a referral value from the private provider. For a child, once

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the value has reached a normal level, it does not have to be determined for another year (the subsequent certification visit closest to that year).
Blood work within the normal range is valid for children for one year beginning at eighteen (18) months of age; however, if the child participant is terminated from the program and re-applies for WIC benefits, blood work will have to be performed again. When a new initial contact date is assigned to the participant, blood work as well as anthropometrics must be taken in the clinic or from referral data to assess for eligibility.
Postpartum, breastfeeding women who have breastfed for 6 months will not have to have blood work performed at their second postpartum WIC certification unless there is a medical reason.
Blood work is not routinely performed on women prior to discharge from the hospital. When postpartum breastfeeding and non-breastfeeding women are certified in the hospital, follow these procedures (if blood work is unavailable): a. Enter the Date of Certification in the Hematological Data
Date field. b. Enter the value 88.8 in the Hemoglobin field. c. If the applicant is assessed WIC eligible, issue up to two
(2) month of vouchers and follow District procedures for obtaining blood work by the next voucher issuance.
Note: Each District must develop a written procedure to be used in obtaining blood work on postpartum breastfeeding and nonbreastfeeding women certified in the hospital. This procedure must be approved by the Office of Nutrition prior to implementation, and written approval must be kept on file in the District Office.

X. NUTRITION RISK CRITERIA
Nutrition risk criteria are set by the State agency, in accordance with federal rules and regulations. The criteria are based on detrimental or abnormal nutrition conditions detectable by hematological or anthropometrics measurements, other nutrition related medical conditions, nutritional deficiencies that impair or endanger health, or conditions that predispose persons to inadequate nutritional patterns or nutritionally related conditions. If no nutritional risks are evident,

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applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are less than 4 months of age.
Nutrition risk criteria, risk factor codes and priority designations used for Georgia WIC Program certification are listed in (Attachment CT-6).
The nutrition risk criteria are listed by applicant/participant status at the time of certification. Each criterion is identified by a three digit numerical code.
The WIC Assessment/Certification forms utilize a checklist format to document the applicable nutritional risk criteria. Refer to CT-XV.B. for information regarding the completion of the WIC Assessment/Certification form.

XI. NUTRITION RISK PRIORITY SYSTEM
A. General Priorities I -VI
Each nutrition risk criterion is assigned a specific priority. Statewide priorities are set in accordance with the following guidelines:
1. Priority I: Pregnant women, breastfeeding women, and infants with nutritional need. This need is determined by measuring length/height, weight, hemoglobin/hematocrit and assessing nutrition status and nutrition related medical history.
2. Priority II: Breastfeeding women who do not qualify under Priority I, but are breastfeeding Priority II infants.
Infants up to six (6) months of age whose mothers were program participants during their pregnancy. Infants up to six (6) months of age whose mothers was not Program participants during pregnancy but had a documented nutritional need.
3. Priority III: Children (under age 5) with a nutritional need. This need is assessed by measuring length/height, weight, hemoglobin/hematocrit and assessing nutrition status and nutrition related medical history.
Postpartum teenagers who are not breastfeeding and whose delivery date was prior to 18 years 10 months of age.

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4. Priority IV: Pregnant women, breastfeeding women, and infants with a nutritional need because of inappropriate nutrition practices or homeless/migrancy status.

5. Priority V: Children with a nutritional need because of inappropriate nutrition practices or homeless/ migrancy status.

6. Priority VI: Postpartum, non-breastfeeding women with a nutritional need, or homeless/migrancy status.

B. Special Considerations

Reciprocal Risk - A breastfeeding mother and her infant shall be placed in the highest priority for which either is qualified.

C. Specific

Each nutritional risk has an assigned priority. The priorities and risk factor codes by participant status are identified below.

1. Pregnant Women

Priority I:

101, 111, 131, 132,133, 201, 211, 301, 302, 303, 311, 312, 321, 331, 332, 333, 334, 335, 336,337, 338, 339, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362,371, 372, 373, 381, 502,904

Priority IV: 400, 401,502, 801, 802, 901, 902

2. Breastfeeding Women

Priority I: Priority II:

101, 111, 133, 201, 211, 303, 311, 312, 321, 331, 332, 333, 335, 337, 339, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362, 371, 372, 373, 381, 502, 601, 602, 904 502, 601

Priority IV: 400, 401, 502, 601, 801, 802, 901, 902 3. Postpartum, Non-Breastfeeding Women

Priority III: 331, 502

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Priority VI:

101, 111, 133, 201, 211, 303, 311, 312, 321, 331, 332, 333, 335, 337, 339, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362,371, 372, 373, 381, 400, 401, 502, 801, 802, 901, 902

4. Infants

Priority I:

103, 121, 134, 135, 141, 142, 153, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 353, 354, 355, 356, 357, 359, 360, 362, 381, 382, 502, 603, 702, 703, 904

Priority II: 502, 701, 702

Priority IV: 400, 401, 502, 702, 801, 802, 901, 902

5. Children

Priority III:

103, 113, 114, 121, 134, 135, 141, 142, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 361, 362, 381, 382, 502,904

Priority V: 400, 401, 502, 801, 802, 901, 902

D. Assignment

At the time of certification, the CPA must assign a priority based on the identified nutrition risk criteria. The highest priority for which a person qualifies must be assigned.

XII. CHANGES WITHIN A VALID CERTIFICATION PERIOD
A. Women Who Cease Breastfeeding
The following procedures must be followed when clinic staff is notified by a woman participant that she is no longer breastfeeding:
1. If the woman is more than six (6) months postpartum, she is categorically ineligible and must be removed from the program immediately (See CT-XVI, Ineligibility Procedures). The termination must be documented in the participant's health record.
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2. If the woman is less than six (6) months postpartum, reassessment of nutrition risk is required. The woman must qualify for WIC based on the risk criteria for a postpartum, nonbreastfeeding woman to continue benefits. If there is a nutrition risk reason, the woman's status, priority, and food package must be changed. If no nutrition risks are evident, Risk Code 401 (Other Dietary Risk / Failure To Meet Dietary Guidelines) can be used for the woman to continue to receive WIC benefits as a postpartum, non-breastfeeding woman until six (6) months from the delivery date. All information must be documented in the participant's health record and entered into the automated system.
B. Upgrading a Priority
New data that has been collected and assessed during the certification period can be used to place a participant in a higher priority. A priority cannot be downgraded during a participant's certification period (with the exception of a breastfeeding woman changing status to a postpartum nonbreastfeeding woman).
XIII. CERTIFICATION PERIODS
Certification periods are:
Pregnant Women: for the duration of their pregnancy and for up to six (6) weeks postpartum. There is no extension granted beyond the six (6) week postpartum cutoff. Breastfeeding Women: for six (6) months from the date of initial and/or subsequent certification as a postpartum, breastfeeding woman. Eligibility ends when the certification period is over, when the breastfed infant turns one (1) or when breastfeeding is discontinued, whichever comes first.
Note: The certification period for the breastfeeding woman is six (6) months, however, she is eligible to be recertified as a breastfeeding postpartum women if she is still breastfeeding an infant less than one (1) year of age.
Postpartum, Non-Breastfeeding Women: for up to six (6) months from the termination of their pregnancy.
Infants: (six [6] months of age or younger): until their first birthday.

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Infants: (greater than six [6] months of age): for six (6) months from date of certification.
Children: for six (6) months from the date of each certification may continue eligibility until they reach their fifth birthday, if assessed at nutritional risk.
Vouchers may only be issued to participants who are in a valid certification period. The certification period always begins with the date of certification. Certification ends on the categorically ineligible termination date (See Food Delivery Section IIIE).
In cases where there is difficulty in scheduling appointments for breastfeeding women, infants, and children, the certification period may be shortened or extended by a period not to exceed thirty (30) days. The specific difficulty must be documented in the participant's health record if a clinic chooses to exercise this option. Vouchers can be issued for the one month extension. Please use this as the exception and not the rule. Document in the participants health record the reason for the extension and issue only one month of vouchers.

XIV. INFANT MID-CERTIFICATION NUTRITION ASSESSMENT
Infants certified prior to six (6) months of age will be subsequently certified on their first birthday. A mid-certification nutrition assessment, by the CPA, should be completed between five (5) and seven (7) months of age. To ensure accessibility to quality health care services, the following procedures must be completed:
1. The initial certification of the infant less than six (6) months of age will follow the standard procedures in IX. Nutrition Risk Determination. The infant shall be assigned the highest priority for which he/she is eligible.
2. The mid-certification nutrition assessment must consist of: a. Measuring length and weight. b. Plotting weight for length, length for age, and weight for age. c. Measuring hemoglobin or hematocrit (if mid-certification nutrition assessment is performed between 9-12 months of age). d. Recording, summarizing, and evaluating inappropriate nutrition practices. e. Assessing nutrition risk criteria. f. Assigning the highest priority for which the infant is eligible, and reviewing food package needs, and assigning an appropriate food package.

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3. The mid-certification nutrition assessment information will be documented in the second column of the Infant WIC Assessment/Certification form if using paper form.
4. If additional risks are identified at any time during the one (1) year certification period, the infant's priority should be upgraded.
5. All infants certified at <6 months of age must be scheduled for a midcertification nutrition assessment. Program benefits may not be withheld from a participant for failing the mid-certification nutrition assessment appointment(s). Missed appointments should be documented in the participant's health record.
Note: Proof of identification, residency and income are not required during the mid-certification assessment. However, if during the mid-certification a participant reveals that their income is above the income guidelines, the participant and ineligible household members will be terminated from the program.

XV. WIC ASSESSMENT/CERTIFICATION FORM
A. General 1. State WIC Assessment/Certification Form Certification data for each applicant/participant will be recorded on the form provided by the State agency or generated by each district's computer system.
2. Local Agency WIC Assessment/Certification Form
If a local agency/clinic chooses to use other forms and/or documentation procedures in the certification process that are different from the procedures outlined in this manual, then all forms and/or procedures must be submitted to the state agency, in writing, for approval prior to implementation. Local agencies that choose to develop their own forms and/or procedures must update them each time the state revises its forms and/or procedures. Any subsequent changes or modifications to the local agency/clinic forms and/or documentation procedures must also be forwarded, in writing, to the state agency for approval prior to implementation of the revised form. Both sides of the certification form must be accurately completed each time an individual is certified. A portion of the required information is

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common to each form. The following are instructions for completion.
B. Completion
All items on the WIC Assessment/Certification form must be completed as follows:
1. Identification Information - Applicant's name, birth date, address, telephone number, ethnic origin, (Hispanic/Latino Yes or No), races [(1) White (2) Black/African American (3) Asian (4) American Indian/Alaska Native and (5) Native Hawaiian/Other Pacific Islander) ] and migrant status, county of residency, proof of residence and proof of identification (for applicant/participant and if applicable parent/guardian/spouse/alternate parent), clinic number, Family ID number, foster care information, WIC ID number and parent or guardian/alternate parent's full name (infants and children only), must be filled in on each form used. All legally responsible persons must be documented in the health record (i.e. name of father/guardian/alternate parent).
The local agency representative must ask the applicant to make a self-declaration of their ethnic origin, race and migrant status and use the WIC Interview Script to collect demographic data. Unknown cannot be used to identify race for the Georgia WIC Program. If the client refuses to answer, staff will make a decision.
2. Breastfeeding Information - Complete each line in this section, using the following information:
Infant's and Children's Forms through age 2 at each certification:
a. Breastfed Now (1) On Infant's Form, check "Yes" if this infant is currently breastfeeding. (2) On Children's Form, check "Yes" if this child is currently breastfeeding.
b. Breastfed Ever (1) On Infant's Form, check "Yes" if this infant was ever breastfed (even if currently not breastfeeding)

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(2) On Children's Form, check "Yes" if this child was ever breastfed (even if currently not breastfeeding)
(3) If the answer is "No", two times for an infant or one time for a child, this question does not need to be asked again.
c. Record the Number of Weeks Infant/Child Breastfed - If using a paper certification form and the infant/child is currently or ever breastfed, record the number of weeks up to a maximum of 99 weeks (2 years of age). (See the key for entering weeks breastfed in Attachment BF-9, Breastfeeding Section.) If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed.
d. Date of Most Recent Breastfeeding Response - Record the date on which you asked the participant/guardian/ alternate parent about breastfeeding.
Women's Form:
a. Postpartum Breastfeeding Assessment/Certification form (Breastfeeding an Infant Less than 1 Year of Age): (1) If using a paper certification form, enter the weeks breastfed in the "Weeks" column. (See the key for entering weeks breastfed in Attachment BF-9, the Breastfeeding Section). If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed. (2) Update the information at time of termination and submit to Covansys.
b. Postpartum Non-Breastfeeding Assessment/Certification form (Less than 6 Months Postpartum): (1) If the woman is not currently breastfeeding but has breastfed, check "Yes" to Breastfed Ever. (2) If using a paper certification form, and if the response to Breastfed Ever is "Yes", enter the weeks breastfed in the "Weeks" column. (See the key for entering weeks breastfed in Attachment BF-9, Breastfeeding Section.) If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed.

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(3) If using a paper certification form, and if the response to Breastfed Ever is "No", enter "0" in the "Weeks" Column. If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed.
3. Initial Contact Date - The initial contact date must be filled in at each certification, even if it has not changed. The initial contact date must be accurately documented to ensure that processing standards are being met. See Initial Application CT-III.A for the definition of "initial contact date".
x Initial Contact Type Select type of Initial Contact x W Walk-in x T Telephone x O Other (explain in notes)
4 Foster Care Enter Yes or No if the applicant is in Foster Care.
5. Medical Data Date - See the Nutritional Risk Determination CTIX for the definition of required medical data. Enter the date anthropometric measurements were taken for certification purposes.
6. Length/Height - Enter the length/height to the nearest eighth of an inch (for infants and children only).
7. Weight - Enter the weight in pounds. and ounces (for infants and children only).
8. Hematological Data Date - Enter the date hematological measurement was taken for certification purposes. Hematological data date must be within d 90 days prior to certification for infants 9-12 months of age, children and women.
9. Hematocrit/Hemoglobin - Enter the hematocrit and/or the hemoglobin value(s) in the appropriate field. Values must be rounded to one decimal place.
10. Nutrition Risk Criteria - Complete each line in this section using the following procedure: a. Check "Yes" when the nutrition risk criterion is present. b. Check "No" when the risk criterion is not present.

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c. Write "N/A" when the risk criterion does not apply or was not assessed.
d. Record additional documentation for risk criterion. Mark with (*).
This section of the form must be completed by a CPA during each certification appointment and at the infant's mid-certification nutrition assessment.
11. High Risk - Check "Yes" when at least one nutrition risk meets the High Risk Criteria (Attachment NE-1 and NE-2, Nutrition Education Section).
12. Eligible for WIC - Check "Yes" when all of the following criteria are met: a. The applicant resides within the State of Georgia, and b. The applicant is income eligible, and c. The applicant is an infant, child, pregnant, postpartum or breastfeeding woman, and d. At least one (1) nutritional risk criterion is checked "Yes." There must always be at least one nutritional risk checked "Yes" for all participants / applicants. CPAs may assign Risk Code 401 (Other Dietary Risk) when no other nutritional risk factors have been identified for participants who are at least 4 months of age. Check "No" when one or more of any of the criteria from the above list are not met (Ineligibility Procedures CT-XVI).
13. Priority - Enter correct priority (I - VI). Refer to the Nutritional Risk Priority System CT-XI for risk factor codes and priorities.
14. Food Package - Enter the appropriate food package code (See Section FP, Food Packages Section).
15. Services - Enter referrals and/or enrollments to other health services and programs using codes listed on the WIC Assessment/Certification form. See Section NE, Nutrition Education, for more information regarding required referrals. Enrollment in or Referral to TANF, Food Stamps and Medicaid MUST be documented.
a. "Enrolled In" is used when a person is already utilizing other health services and programs.
b. "Referred To" is used when a person has been given

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information regarding other health services and programs.
16. Today's Date - Enter the date the assessment is completed.
17. Signature/Title - Enter signature (first name and last name) and title (Nutr., R.D., L.D., R.N., M.D., etc.). An appropriate signature consists of first name, last name and title. The local WIC official signature confirms the nutrition medical risk.
18. Income Assessment
a. Date - Fill in the date the income screening was completed
b. Number in Family - Fill in according to Income Eligibility CT-VIII.
c. Gross Income/Month
1. Medicaid Recipients {(See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.1)} Mark yes (Y) if Medicaid participation has been confirmed. Medicaid recipients must self declare income.
2. PeachCare Recipients {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.2.)}. All PeachCare clients must be assessed for WIC income eligibility.
3. Food Stamp Recipients - {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.3)} Mark yes (Y) if Food Stamp participation has been confirmed.
4. Temporary Assistance for Needy Families (TANF) - {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.4)} A "notice of case action" issued to TANF participants, with dates of eligibility for any TANF benefit, is acceptable proof of current enrollment in TANF. Mark yes (Y) if the participant has documented proof that they receive TANF.
5. Participants not receiving Food Stamps, Medicaid, or TANF - Complete according to CT-VIII. C. Computing Income.

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6. Income Eligibility - Check "Yes" or "No" to indicate applicant's income status. Transfer the total from the Income Calculation form to the section of the Certification form. Indicate the total number in the family. The Income Calculation form must be used to determine income eligibility, if the applicant has more than one source of income and does not quality for Medicaid, Food Stamps or TANF. Record current annual income.
Note: Income must be recorded for all applicants, including applicants who receive Medicaid, Food Stamps and TANF.
7. Income Source - Record, document and review for proof of income.
d. Staff Initial The staff person who confirms income, residency and ID maybe different from the person who signs the form. Therefore, the staff who collected this information must enter his/her initials.
e. Staff Signature(s) - The local WIC official signature confirms the income, residency and family size are correct as stated by the applicant/participant. The signature also verifies/witnesses the participant's signature. An appropriate signature consists of first and last name; title of person verifying income.
f. Date - The date must be completed by the participant, their authorized representative or the attending staff person.
g. Applicant/Participant Signature - The participant, parent/guardian/spouse/alternate parent or proxy must be asked to read and sign the following statement each time they are certified (if unable to read, must have it read to them):
I have been advised of my rights and obligations under the program. I certify that the information I will provide, or have provided, is correct to the best of my knowledge. The income I have given is my total gross

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household income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the Georgia WIC Program may give my certification information to the Immunization Program, Pregnancy Risk Assessment Monitoring System (PRAMS) , Epidemiology and other public health assistance programs to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.
h. Applicant Unable to Write - If the applicant/participant/ authorized representative is unable to write, he/she will enter his/her mark in lieu of a signature. The staff person will print the person's name next to the mark, and initial and date the mark to indicate that it has been witnessed.
19. Physical Presence
Certification Form (Back) Physical Presence If the response is "NO", N, D, R or W must be selected:
x (N) Newborn-Infants who are born to a mother who was on WIC during her pregnancy or was eligible to participate but was not certified. The infant must be brought into the clinic prior to two (2) months of age to avoid termination. Medical or high risk condition may not be present.
x (D) Disabilities The local agency must grant an exception to applicants who are qualified individuals with disabilities and are unable to be physically present at the WIC clinic because of their disabilities, or applicants whose parents or caretakers are individuals that meet this standard. Examples of such situations include: a. A medical condition that necessitates the use of medical equipment that is not easily transported. b. A medical condition that requires confinement to bed

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rest; and c. A serious illness that may be exacerbated by coming into
the WIC clinic. x (R) Receiving ongoing Health care An infant or child who
was present at his/her initial WIC certification and has documentation of ongoing health care from a health care provider (other than the local WIC agency) may be exempt from physical presence requirements by the local agency, if unreasonable barriers exist. x (W) Working parent or caretakers The local agency may exempt an infant or child from the physical presence requirements: a. If the infant/child was present for his/her initial WIC
certification; b. If the infant/child was present at a WIC certification
within the last year and determined eligible; and c. If the infant/child is under the care of working
parents/guardian whose status presents a barrier to bringing the infant/child into the WIC clinic.
20. Immunization Status Infant and Children Form:
The immunization status is required during initial certifications and Subsequent certifications for infants (over 6 months of age) and children.
(1) Record Screened/Requested Yes ( ) Requested ( )
(2) Adequate for Age/Referred? Yes ( ) Doctor ( ) Health Dept ( )
21. Data Needed for Pregnancy Surveillance Infant's Form: (1) Mother's WIC ID# - Enter the full name and/or WIC ID number of the mother, if the mother is currently a WIC participant.
(2) Last Weight Before Delivery - Enter the last weight of the mother, taken prior to delivery. Round the weight to the nearest whole pound, e.g., 165 = 165.
Women's Form:

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(1) Marital Status - Enter numerical code indicating current marital status, i.e., 0=married, 1=not married, 9=unknown.
(2) Years of Education Completed - Enter a 2-digit number to indicate years of education completed, e.g., 01=1st grade, 02=2nd grade, 14=2 years of college, 99=unknown.
(3) Month of Gestation at Time of First Prenatal Exam Enter a one-digit code to indicate the month of gestation at the first prenatal exam, e.g., 0=No Prenatal Care, 1=1st . Delivery - Enter the last weight taken prior to delivery, rounded to the nearest whole pound, e.g. 165.6 = 166.
(5) Parity A 2-position field indicating the number of times a woman has been pregnant for 20 or more weeks gestation, regardless of whether the infant was alive or dead ( stillbirth, miscarriage induced or abortion) at birth, e.g., 00=None, 01-29=Number of previous births.
(6) Date of Last Pregnancy Ended A 6-position field indicating the date when the previous pregnancy of at least 20 weeks or more ended, whether by normal delivery, stillbirth, induced or spontaneous abortion (miscarriage) excluding current pregnancy, e.g., 000000= No Previous Pregnancies, Month/Year=01-12 and All four digits.
(7) Diabetes During Pregnancy Postpartum Visit - A 1position field indicating the presence of diabetes during this current pregnancy, as diagnosed by a physician and self-reported by the postpartum woman or as reported or documented by a physician or someone working under a physician's orders, e.g., 1=No, never had diabetes of any type. 2= Yes, told by a doctor I had diabetes before the most recent pregnancy, when not pregnant (diabetes mellitus). 3=Yes, told by a doctor I had diabetes before the most recent pregnancy, but only when pregnant (gestational diabetes in both past and most recent pregnancies). 4=Yes, told by a doctor I had diabetes for the first time during the most recent pregnancy (gestational diabetes in the current pregnancy only).

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(8) Hypertension During Pregnancy Postpartum Visit - A 1- position field indicating the presence of hypertension during pregnancy as diagnosed by a physician or someone working under a physician's orders and selfreported by a woman, e.g., 1=No, never had high blood pressure before the most recent pregnancy, when not pregnant (chronic hypertension). 2= Yes, told by a doctor I had high blood pressure before the most recent pregnancy, when not pregnant (chronic hypertension). 3= Yes, told by a doctor I had high blood pressure before the most recent pregnancy, but only when pregnant (pregnancy-induced hypertension in both past and most recent pregnancies). 4= Yes, told by a doctor I had high blood pressure for the first time during the most recent pregnancy (pregnancy-induced hypertension in the current pregnancy only).
(9) Multi/Prenatal Vitamin Consumption Prior to Pregnancy - A 1-position field indicating an average of how many times per week a woman took a multi/prenatal vitamin in the month before pregnancy, e.g., 0=Less than once per week , 1-7= Times per week, 8= Eight or more times a week, 9=unknown.
(10) Multi/Prenatal Vitamin Consumption During Pregnancy A 1- position field indicating if a pregnant woman has taken multi/prenatal vitamins and/or minerals in the past month, e.g.,1=Yes, 2=No and 9=Unknown.
(11) Cigarettes/Day 3 Months Prior to Pregnancy A 2position field indicating the average number of cigarettes the woman smoked per day during the 3 months before she became pregnant, e.g., 00=Did not smoke, 0196=Number of cigarettes smoked per day, 97=97 cigarettes per day or more, 98=Smoked, but quantity unknown, 99=Unknown or refused.
(12) Cigarettes per Day Prenatal Visit - A 2-position field indicating the average number of cigarettes the woman currently smoked per day at her prenatal visit, e.g., 00=Did not smoke, 01-96=Number of cigarettes smoked per day, 97=97 cigarettes per day or more, 98=Smoked,

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but quantity unknown, 99=Unknown or refused.
(13) Cigarettes per Day Postpartum Visit A 2-position field indicating the average number of cigarettes the woman currently smoked per day at her postpartum visit,e.g., 00=Did not smoke, 01-96=Number of cigarettes smoked per day, 97=97 cigarettes per day or more, 98=Smoked, but quantity unknown, 99=Unknown or refused.
(14) Cigarettes/Day Last 3 Months of Pregnancy A 2 position field indicating that average number of cigarettes the woman smoked during the last 3 months of her current or most recent pregnancy. This is reported at the postpartum visit only, e.g. 00=Did not smoke, 0196=number of cigarettes smoked per day, 97 = 97 or more, 98 = smoked but quantity unknown, 99=Unknown or refused.
(15) Household Smoking Prenatal Visit A 1-position field indicating whether anyone in the household other than the pregnant or postpartum women currently smokes inside the home, e.g., 1=Yes, someone else smoke inside the home, 9=Unknown. 2= No, no one else smokes inside the home.
(16) Household Smoking Postpartum Visit A 1-position field indicating whether anyone in the household other than the pregnant or postpartum women currently smokes inside the home, e.g.,1=Yes, someone else smokes inside the home, 2-No, no one else smokes inside the home, 9=Unknown.
(17) Drinks/Week 3 Months Prior to Pregnancy A 2position field indicating the average number of drinks per week of beer, wine or liquor the woman consumed during the 3 months before her current or most recent pregnancy, e.g., 00=Did not drink, 01= 1 drink per week or less, 0220=number of drinks per week, 21=21 or more drinks per week, 98=Drank, but quality unknown, 99=Unknown or refused.
(18) Drink/Week Last 3 months of Pregnancy A 2-position field indicating the average number of drinks per week or

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beer, wine, or liquor the woman consumed during the last 3 months of her current or most recent pregnancy. This is reported at the postpartum visit only, e.g., 00=Did not drink, 01=1 drink per week or less, 02-20=Number of drinks per week, 21=21 or more drinks per week, 98=Drank, but quantity unknown, 99=Unknown or refused.
22. Comments (Proxy 1/Proxy 2) This section may be used to maintain a record of proxy names authorized by participants or parents/alternate parent/spouse at certification. Review names prior to voucher issuance.
23. 2010 Questions added to the Certification forms (P,N,B,I and C):
Breastfeeding The "Food Package" row has been expanded to include space to record the infant's food package code. If the infant has not yet been certified or if the mother has delivered multiple infants (e.g., twins, triplets, etc.), the CPA should enter "AAA" in this box on the certification form or in the computer system. The purpose of this field is for the computer to perform a cross-check between the mother's and infant's food package codes to ensure the mother is receiving an allowed food package.
1. Woman's Feeding Method (E, M, S). The CPA is to identify whether the breastfeeding woman is classified as Exclusively, Mostly, or Some breastfeeding.
Non-Breastfeeding, Breastfeeding, Infant and Children 1. Date breastfeeding began (MMDDYYY) 2. Did Breastfeeding begin at birth? (Y or N ) 3. Date of last time of breastfeeding and/or pumping
(MMDDYYY)
Children Recumbent/Standing (R or S). The CPA is required to identify whether a child was measured in a recumbent (R) or standing (S) position.
Infant Infant Feeding Type (E, M or F). The CPA is to identify whether the infant is receiving an Exclusively Breastfed, Mostly Breastfed,

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or Fully Formula Fed food package. Infant and Children 1. Medical Home (Y or N), If yes, enter name of physician or
practice. 2. PeachCare (Y or N)
Prenatal, Non-Breastfeeding, Breastfeeding, and Children 1. Fruit Intake (D, S or N). The CPA is to indicate whether
the applicant / participant consumes fruit daily, some days of the week, or never. 2. Vegetable Intake (D, S or N). The CPA is to indicate whether the applicant or participant consumes vegetables daily, some days of the week, or never. 3. Usual Daily Activity (V, S or N). The CPA is to indicate whether the applicant / participant is very physically active, somewhat active, or not active.
Prenatal, Non-Breastfeeding, Breastfeeding, Infant and Children Family Number

XVI. INELIGIBILITY PROCEDURES (NOTIFICATION REQUIREMENTS)
Persons may be ineligible or disqualified for Program benefits on the basis of residency, category, income or nutritional risk; however, infants less than 4 months of age are the only participants / applicants who potentially can be disqualified based solely on the lack of nutritional risk (due to the introduction of Risk Code 401, which can be used to document presumed nutritional risk for all otherwise eligible persons who are age 4 months or older). All applicants/participants who do not meet program requirements and are assessed to be ineligible or disqualified for WIC benefits must be notified of ineligibility, in writing. The Notice of Termination/Ineligibility/Waiting List (NTIWL) Form is official documentation that local agencies must use to notify applicants/participants of ineligibility or termination (Attachment CT-14 or CT-15).
When applicants/participants are ineligible or terminated from the program and a NTIWL is issued, they must be informed of their right to a fair hearing. A fair hearing may be requested when program participation is denied or a participant is disqualified for benefits (See Fair Hearing Section in Rights and Obligations).

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Local agencies must follow program procedures for "written notification" and "processing standards" whenever an ineligibility/termination decision is made. All procedures followed must be documented in the health record or agency file.
The following notifications shall be made in writing and comply with programmatic time frames:
A. Written Notification
1. Ineligibility - An applicant/participant determined to be ineligible for program benefits on the basis of residence, income, or nutrition risk will receive a Notice of Termination/ Ineligibility/Waiting List form on site, which states the reason(s) for ineligibility. If the applicant/participant is assessed over the income limits, a copy of the document viewed must be placed in the Ineligibility file. These files must be maintained for three years plus current year. A copy of the form will be filed in the individual's health record and/or the Ineligibility file.
Note: Completion of the Fair Hearing Section of the Notice of Termination/Ineligibility/Waiting List (NTIWL) Form is required.
2. Expiration of Certification Period - Each participant will be notified at least (15) days before the expiration of their certification eligibility period that it is about to expire. Homeless participants will be notified at least (30) days before the expiration of their certification period.
3. Disqualification - A participant who is about to be disqualified from program participation at any time during the certification period must be notified, in writing, at least fifteen (15) days before benefits end. Reasons for this action and of the right to a fair hearing must be provided. In the event the state agency mandates that the local agency must suspend or terminate benefits to participants due to a shortage of funds, The NTIWL Form must be issued to the participant. A copy of this form must be filed in the individual's health record.
4. Termination Notification - Notification does not need to be provided to persons terminated for failing to pick up vouchers for two consecutive months and failing to return for subsequent certification provided the participant has been given or read the

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Rights and Obligations.
5. Interim Income Change (Reassessment of Income Eligibility) Individuals will be disqualified at any time during the certification period when family income exceeds eligibility requirements. A fifteen (15) day notice must be issued.
B. Completion of Notice of Termination/Ineligibility/Waiting List Form
1. Fill in applicant's name and the date at the top of the form including the date of birth, phone number, and address.
2. Mark the box with the correct option and check the reason for termination.
3. Complete the information at the bottom of the form regarding the name and address of the WIC Program. The Fair Hearing Section must be completed when using this form. If a stamp is used for this purpose, all copies must be stamped. The form must be signed by the parent/spouse/ guardian/ alternate parent and the WIC representative. Appropriate documentation and termination procedures must be followed. A written notice of termination must be given for each member of the family on the program.
C. Ineligibility File
Clinics are required to maintain an Ineligibility file. The five items listed below are critical and must be presented when a fair hearing is requested by an applicant or other persons acting on behalf of an applicant. Each clinic may establish their own system for maintaining such a file, as long as the following guidelines are followed:
1. Ineligible Applicants without Health Records: For applicants who do not have a health record in the clinic, the Ineligibility file must contain the following: a. Applicant's name b. A copy of the NTIWL Form (Completely fill out with signatures, dates and the Fair Hearing Section); c. The date the ineligibility action was taken. d. WIC Assessment/Certification form (Complete all sections on the WIC Assessment/Certification form when an applicant is not eligible for the program. This includes income documentation, date, signature of the participant or applying parent/guardian of the participant and the

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signature of the person who collected income information). e. All supporting documentation, e.g. nutritional assessment, growth charts, progress notes, Income Calculation form, etc.
2. Ineligible Applicants with Health Records:
The five items listed above must be documented and may either be filed in the applicant's health record or in the Ineligibility file. For those who have these items filed in their health records, a list of their names or a copy of their NTIWL Form must be kept in the Ineligibility file. If a copy of their NTIWL Form is filed in the ineligibility file, it does not also need to be filed in the health record.

XVII. TRANSFER OF CERTIFICATION
WIC certification is transferable during a valid certification period. Paper and electronic Verification of Certification (VOC) cards (Attachment CT-16 and 17) are the official documents for validating WIC certification nationwide. VOC cards (paper and electronic) are negotiable instruments used to validate WIC certification. These cards allow WIC participants to transfer certification from one clinic, city or state to another. Local agencies must maintain accurate records of issuance, security and receipt from participants.
A. Clinic Staff Clinic staff must: 1. Inform all WIC participants that they should request a VOC Card if relocating anytime during their eligibility period. All migrant farm workers must be issued VOC cards upon arrival in the clinic. For non-migrant participants transferring within the State of Georgia only, a copy of both sides of the WIC Assessment/Certification Form may be given to a participant in lieu of a VOC card. However, original records must be retained at the initial clinic site.
2. Instruct the participant on the use of the VOC card.
3. Do not issue an EVOC/VOC card to a proxy.
When an applicant transfers in with a VOC card, the parent,
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guardian, or caretaker is not required to bring the infant or child.
4. When transferring from one clinic to another (in-state or out-ofstate), the participant or parent/guardian/spouse/alternate parent must present the VOC card, proof of identity, and residency documents. The Thirty-Day Form can not be used for missing proof information.
Note: A Notice of Termination Waiting List (NTIWL) (Attachment CT-14 or CT-15) form must be issued on site, when a VOC card is issued to a participant, with the exception of a migrant participant.
B. Out of State Transfer
Out-of-state participants with a valid VOC card must be placed on the program even if they do not meet Georgia's eligibility criteria. Local agencies must be aware that some states use the combination WIC ID/VOC card and must read all VOC cards carefully. Under no circumstances should a WIC participant transferring into a clinic with a valid VOC card be denied WIC benefits or reassessed for eligibility. Transfer with valid VOC cards or other valid certification evidence (i.e. certification record, valid proof of identification and residency) must be enrolled immediately. If information is missing, contact the clinic and ask the staff to fax or e-mail the required information as soon as possible. The only reason vouchers are replaced is when a fire occurs and part of the voucher and/or WIC ID card is found. Proxies cannot present this information for the participant.
For participants transferring in from another state who are on a special formula or medical food and who have a different medical documentation form:
A CPA must review the medical documentation form to ensure that all information required by the Georgia WIC Program is present, that the form was signed by a health care provider authorized to sign prescriptions, and that the form has not expired (i.e., was signed and dated less than 6 months ago).
For participants transferring in from another state who are on a special formula or medical food but who do not have any medical documentation:
No vouchers can be issued for special formulas or medical foods until medical documentation is obtained, even if the participant has unused vouchers for a special formula product. Other states may or may not require

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medical documentation for a special formula that does require medical documentation in Georgia (e.g., Similac Sensitive or ProSobee LIPIL/Enfamil Soy LIPIL) depending on the formula contract and policies of the other State WIC Program. The CPA can attempt to get a verbal order from the prescribing health care provider in the other state, can contact the originating WIC clinic to attempt to obtain a copy of existing documentation, or can refer the participant to a local provider for evaluation.
C. In-State Transfer
If clinic staff is unable to obtain the necessary information by phone for a Georgia participant, a valid Georgia WIC ID card may be accepted in lieu of a VOC card with proper ID and proof of residency. This should be done only when immediate certification seems imperative and staff feels the ID card strongly indicates that the individual is eligible. A participant who is transferred using a Georgia WIC ID card will be issued vouchers for one (1) month, unless the participant is receiving a special formula, medical food, or special food substitution requiring medical documentation. Medical documentation must be up-to-date and verified prior to issuance of any vouchers for products requiring medical documentation. Prior to the next issuance, clinic staff must contact the certifying clinic for verification of eligibility and certification information. All transfer certification information must be in the participant record within two (2) weeks of the transfer. The phone call and all information obtained must be documented in the participant's health record. The call must be followed with written documentation from the clinic.
It is recommended that each District establish procedures to make it easy for other WIC clinics to obtain the information needed to complete a transfer. This could include a staff member assigned to handle all transfer requests. Also if the clinic uses automatic phone transfers to have the voice message indicate to which extension transfer request should be routed.
D. Release of Information/Original Certification Form (In-State/Out of State)
The United States Department of Agriculture (USDA) approved the Georgia WIC Program to release participants WIC record form one WIC clinic to another WIC clinic without completing a Release of Information form. The original WIC Assessment/Certification form must be retained in the District/Clinic where the participant was certified. Below are some scenarios for transferring a WIC client:

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Intra-State (within the state of Georgia): When transferring a participant from one Georgia WIC clinic to another Georgia WIC clinic, a Release of Information form is not required to fill out or signed. The WIC staff of the receiving clinic should call the original clinic and obtain all necessary information required to complete the transfer process. The original clinic must verify that the receiving clinic is a genuine clinic and provide the participants information. In addition, the original clinic must send a signed copy of the current Certification form to the receiving clinic as soon as possible, preferably by fax.
Out of State Transfer: When transferring a participant from out of state, the Release of Information form is not required. The above (in State) policy applies to the out of state participants as well.
Transferring a WIC record to a non WIC Program: (Parent of the Child or Private Doctors) A Release of Information form must be filled out and signed by the participant or parent of the participant before releasing any WIC information to any other agency/program other than WIC. The WIC staff must keep the original record/document in the original clinic. If a mother wants to transfer her child to another WIC clinic and want to take the WIC record with her (hard copy), the mother must sign the Release of Information form.
If other health program such as Immunization, private doctors, DFAC wants the WIC record, a Release of Information form must be completed before releasing any WIC information.
If a WIC staff is releasing any other medical/health information other than WIC information, a Release of Information form must be filled and signed.
Transferring a Foster Child: When transferring a foster child from one WIC clinic to another WIC clinic, intra-state policy also applies. If a foster child is placed in a different home during the valid certification period, the foster parent must present all legal documentation. The new foster parents should sign a Release of Information Form.
Note: At any time a clinic refuses to send information without a completed Release of Information form, the requesting clinic must write down the name of the employee, clinic, and date the

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information was requested, and pass the information the State WIC office, Policy Unit. However, a participant must not suffer, in this situation, please send a Release of Information form to serve the participants.

E. Two Methods for Transfer
The Georgia WIC Program has two (2) methods for VOC cards. They are Electronic and Paper VOC cards issuance.
1. The Electronic VOC Card System
a. The Electronic EVOC card system automatically: 1. Prints the card 2. Completes the Inventory 3. Conducts a Physical Inventory 4. Prints your initials 5. Gives Clinic Manager and Coordinator assess for security reasons
b. The Electronic VOC card system procedure requires: 1. Logging into the VOC card computer system 2. Entering your password 3. Entering necessary data in your VOC card system 4. Printing two copies of the EVOC Card x The first signed copy is to be given to the participant. x The second copy must be placed in the Medical record or EVOC card file. If the printing system is linked in GWIS or the GWIS.NET, clinic staff is only required to enter the WIC ID, and the required fields will be populated automatically. If the system is not linked to GWIS.net, all required fields on the computer screen must be completed.
c. Quarterly Report for Electronic VOC Card & Paper VOC Cards On the last working day of the months of December, March, June and September of each year, clinic staff is required to print a copy of their EVOC card inventory and place it in a file for audit purposes. Additionally, each Nutrition Services Director and office manager will have permission to view the EVOC card files at any time for security purposes.

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d. Printing Electronic VOC Cards EVOC card information is to be printed on regular white 8 x 11 paper. However, an official EVOC card must be stamped with the Georgia WIC stamp using BLACK INK.
e. Termination Notices Once the EVOC card information is entered, a Notice of Termination/Waiting List form will be generated automatically stating the participant has moved out of the area. The only exception to printing a Notice of Termination/Waiting List form is when a card is issued to a Migrant.
f. Migrant Transfer When a migrant visits your clinic, automatically issue an EVOC card. However, you must not issue a termination letter unless their certification is ending.
g. Required Data Required data on the EVOC and paper card is as follows: 1. Clinic # 2. Participant/Parent/Guardian/Name 3. Telephone 4. Address 5. ID # 6. Date of Birth 7. Participant Name 8. Telephone 9. Participant Address 10. Certification Date 11. Height 12. Date Certification Expires 13. Medical Data Date 14. HGB or 15. HCT 16. Weight 17. Food Package 18. Priority 19. EDC Date 20. Migrant (must be checked yes/no) 21. Nutritional Risk Code (use national risk codes) 22. Intended City/State moving to 23. Date of Latest Income Eligibility

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24. Last Date Vouchers Issued
The signature of the WIC official as well as the WIC applicant is required on the EVOC card. Remember: A VOC card must not be issued to a proxy. h. Physical Inventory No physical inventory is required for the EVOC system.
2. The Manual VOC Inventory System The Manual VOC Card Inventory System is a backup system in the event the computer system crashes. This system requires: a. Security of VOC Cards b. Quarterly Physical Inventory c. Issuance d. Counting of cards quarterly e. Signature of person who conducted the inventory and the initials of the person verifying the inventory.
F. Ordering VOC Cards
VOC cards can be ordered by the clinic directly from the State or District Office. The District Office shall determine how/when clinics order VOC cards. In the event the District Office agrees that VOC Cards may be ordered directly from the State, the coordinator must submit a VOC Card Agreement (Attachment CT-21) and a VOC Card form (Attachment CT22). These two forms must be completed, signed and forwarded to the Georgia WIC Program at the address below. No orders will be accepted from any clinic unless these forms have been received.
The VOC Agreement (Attachment CT-21) must be completed by the WIC Coordinator who must indicate which clinic representative is responsible for requesting VOC Cards from the State. NO PHONE CALL REQUESTS WILL BE HONORED.
When ordering VOC cards directly from the State, an order form (Attachment CT-23) must be completed and mailed to: The Georgia WIC Program, c/o Policy Unit, 2 Peachtree Street, NE, Atlanta, Georgia 30303. A minimum of five (5) paper cards must be on hand.
G. Inventories
All local agencies and clinics are responsible for maintaining an inventory of all VOC cards. The State VOC Card Inventory Logs (Attachments CT-

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19 and CT-20) must be used by all local agencies and clinics. When VOC cards are received, the following must be recorded on the inventory log: 1. The date. 2. The numbers series must be recorded in the beginning/ending
number columns. 3. The number of VOC cards received. 4. Total number of VOC cards on hand. 5. Staff initials must be recorded on the inventory log.
The above documentation must be completed the same day the VOC cards are received by a responsible WIC staff person. VOC cards must be used in the order in which they were received; first in, first out. All VOC cards must be used in sequential order until depleted. A physical inventory of VOC cards must be performed quarterly (December, March, June, and September) by local agencies and clinics. The following must be recorded on the inventory log: 1. The date 2. The numbers series must be recorded in the beginning/ending
number columns. 3. Document "Physical Inventory Conducted". 4. Total numbers of cards on hand. 5. Initials of staff person conducting the physical inventory. 6. Initials of staff person verifying the physical inventory. 7. All VOC cards must be accounted for and the log must accurately
reflect the disposition of each VOC card.
H. Issuance
A record of the issuance of each card must be maintained. When a VOC card is issued to a participant in the clinic, the following must be recorded on the inventory log (Attachment CT-19): 1. Date the card was issued. 2. VOC card number. 3. Participant's name. 4. Participant's WIC ID number. 5. Signature of Parent/Guardian/Alternate Parent/ (A proxy
cannot pick up a VOC Card). 6. Name/City/State participant is moving to. 7. Number of cards on hand. 8. Initials of the staff person issuing the card.
When VOC Cards are issued to the local agency, the following information must be documented (Attachment CT-20):

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1. Date. 2. VOC card numbers series issued (beginning/ending number
columns). 3. Number of cards issued. 4. Name of receiving clinic. 5. Name of clinic representative at the receiving clinic. 6. Total number of cards on hand. 7. Initials of one (1) clerical staff and a second staff member.
I. Security
VOC cards are negotiable instruments; therefore, the security of the cards and the accompanying inventory log is imperative. VOC cards, their inventory log and the WIC stamp must be stored in separate locked locations.
Only authorized personnel may have access to the VOC cards/inventory log. These authorized personnel are determined by the local agency.
When the state office mandates that old stock of VOC cards are replaced with revised ones, complete the Lost/Stolen/Destroyed/Voided Vouchers Report (Attachment FD-16) with following:
a. Current Date. b. VOC Card number series (beginning/ending numbers). c. Quantity. d. Status.
Retain a copy in the clinic and forward a copy to the Georgia WIC Program, Policy Unit. Document the destroyed VOC Cards on the VOC Card Inventory Log with the following:
a. Current Date b. VOC Card number series (beginning/ending numbers) c. Document "Destroyed" d. Number on hand e. Initials of staff person destroying VOC cards f. Initials of staff person verifying that the VOC cards were
destroyed
J. Lost/Stolen/Destroyed EVOC or VOC Cards
In the event an EVOC or VOC Card is lost, stolen or destroyed, contact the Policy Unit immediately and complete the Lost/Stolen/Destroyed/ Voided Voucher Report. This report is located in the Food Delivery

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Section.
Anytime an EVOC or VOC Card is lost, stolen, destroyed, an Action Memo will be sent to all Local Agencies by the State Agency so that you are aware of the status of the card. EVOC or VOC Cards must not be reissued to WIC participants within a certification period. If an EVOC or VOC Card is issued to a participant and they later say that they lost it; inform the participant you will send the information to the new location.
When five (5) or more VOC Cards are lost, stolen or misplaced, the Notification Summary of Missing Vouchers/VOC Card form must be completed (See CA Section). Once this report is received, an investigation will be conducted by the Office of Fraud and Abuse in the Department of Community Health.
When there is any discrepancies in the EVOC card system noted, an investigation will automatically take place.

XVIII. WIC OVERSEAS PROGRAM
A. General
The Department of Defense (DOD) has implemented a program overseas similar to WIC. This program is called the WIC Overseas Program. DOD recently began to phase in implementation of the WIC Overseas Program in five (5) locations. These locations include: 1. Lakenheath, England (Air Force) 2. Yokosuka, Japan (Navy) 3. Baumholder, Germany (Army) 4. Okinawa, Japan (Marines and Air Force) 5. Guantanamo Bay, Cuba (Navy)
Additional WIC Overseas Programs will be phased in at other locations where WIC Overseas Program services and benefits can be provided. Information about DOD's WIC Overseas Programs can be found on the TRICARE Website at: http://www.tricare.osd.mil.
B. Impact on USDA's WIC Programs
Legislation limits eligibility in the WIC Overseas Program to:

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1. Members of the armed forces (and their dependents) on duty at stations outside the U.S. and their dependents
2. Civilians who are employees of a military department (and their dependents) (i.e. Army, Navy or Air Force) who are U.S. nationals and live outside the U.S and their dependents
3. Contractors employed by DOD who are U.S. nationals living outside the U.S. and their dependents as defined by DOD. All other eligibility requirements for the WIC Overseas Program mirror USDA's WIC Program requirements. Therefore, DOD guidelines provide that WIC Program participants who are transferred overseas and meet eligibility requirements are eligible to participate in the WIC Overseas Program until the end of the certification period. Additionally, any WIC Overseas Program participant who returns to the U.S. with a valid WIC Overseas Program Verification of Certification (VOC) Card must be provided continued participation in USDA's WIC Program until the end of his/her certification period. The WIC Overseas VOC Card is a full-page document, which also serves as a Participant Profile Report (Attachment CT-35).
Note: A "dependent" includes a spouse and "U.S. national" who are U.S. citizens or individuals who are not U.S. citizens but owe permanent allegiance to the U.S. as determined in accordance with the Immigration and Nationality Act.
C. New EVOC or VOC Card Requirements
State and local agencies must begin to issue WIC EVOC or VOC Cards to WIC participants affiliated with the military who will be transferred overseas. WIC participants issued EVOC or VOC cards when they transfer overseas must be instructed that:
1. There is no guarantee that the WIC Overseas Program will be operational at the overseas sites where they are being transferred.
2. By law, only certain individuals (as defined in Section B above) are eligible for the WIC Overseas Program.
3. Issuance of a WIC EVOC or VOC card does not guarantee continued eligibility and participation in the WIC Overseas

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Program. Eligibility for the overseas program will be assessed at the overseas WIC service site.
D. Completion of the EVOC or VOC Card
When completing the EVOC or VOC card for a transfer overseas, please follow the same procedures outlined in CT-XVII. E.l.g. TRANSFER OF CERTIFICATION SECTION (Required Data). Special emphasis should be placed on completing these cards with the necessary data to prevent long distance overseas communications.
E. Acceptance of WIC Overseas Program EVOC or VOC Cards
Local agencies must accept a valid WIC Overseas Program VOC card presented at a WIC clinic by WIC Overseas Program participants returning to the U.S. from an overseas assignment. Follow the current procedures outlined in the CT-XVII. B. TRANSFER OF CERTIFICATION SECTION (Out of State Transfer).
If questions arise about the VOC Card presented, a current list of WIC Overseas Program contacts is attached (Attachment CT-36). The list of current contacts will be revised on the website mentioned. Local agencies are also reminded that individuals presenting a valid VOC card must provide proof of residency and identification (with limited exceptions) in accordance with WIC Program regulations and policies.

XIX. CORRECTING OFFICIAL WIC DOCUMENTS
A. Correcting Mistakes
The following procedure must be followed when a mistake is made on an official WIC document:
1. Make a single line through the error 2. Initial 3. Date 4. Make the correction near the line 5. Write the word error just above the actual error (optional).
B. Adding Information

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The following procedure must be followed when it is necessary to write additional information on an official WIC document:
1. Write new information 2. Initial 3. Date

XX. LATE ENTRY CORRECTION OF HEALTH RECORDS
Upon receipt of WIC records from another clinic, review the record for missing information. If information is missing, the receiving clinic may add the missing documentation according to the following procedure:
1. Write the words LATE ENTRY (in caps) in the space where the correction needs to be made.
2. Make the necessary adjustments. 3. Sign your initials and date the change. 4. Any other corrections should be made according to the procedure which
is currently outlined in the Georgia WIC Procedures Manual.

XXI. DOCUMENTATION PROCEDURES
1. All WIC documentation must be typed or completed in blue or black nonerasable ink.
2. Never use a pencil or red ink. 3. Do not use correction fluid (white out), scratch out or write over the error. 4. Do not, under any circumstances, alter WIC vouchers. "Official WIC documents" include, but are not limited to: WIC Assessment/ Certification forms, ID cards, VOC cards, voucher registers, inventory logs, vouchers, voucher receipts and health records.
XXII. CERTIFIED WAITING LIST
A Certified Waiting List is intended to facilitate the placement of participants on the program as soon as additional program funds are made available. If it becomes necessary, the Georgia WIC Program shall determine when a waiting list will be implemented.

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A. Procedures for Maintaining a Waiting List
1. A waiting list shall be maintained for individuals who qualify and express an interest in receiving program benefits. Applications must be kept in order, according to the date and priority they were placed on the waiting list.
2. The waiting list must include the following information to facilitate contacting the applicant when caseload space becomes available: a. Date applicant was placed on the waiting list. b. Applicant's address and telephone number. c. Applicant's status (e.g. pregnant, breastfeeding, age of applicant, etc.). d. Applicant's priority.
Note: The Notice of Termination/Ineligibility/Waiting List form should not specify the length of time (no specific date) for remaining on a waiting list (Attachment CT-14 or CT-15).
B. Procedures for Removal from the Waiting List
The Program Nutrition Services Director or designee must ensure that the following procedures are followed when removing persons from the waiting list, as caseload expansion is re-established:
1. Only those individuals who are still categorically eligible need to be contacted. All others can be periodically purged from the list.
2. Those persons on the waiting list who are still in a current certification period will be contacted to come to the clinic immediately to receive vouchers. All others will be informed that current medical data is required and must be evaluated before certification will be possible.
3. Applicants will be contacted by phone or letter.

XXIII. SYSTEM INFORMATION MANAGEMENT
All Automated TAD and Voucher System (ATVS) clinics have been converted to AEGIS at this time. All clinics are now able to utilize the Electronic Verification of

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Certification program via GWIS.net or GWIS. Additionally, the WIC Monitoring Tool is being updated to an electronic version for State and Local Staff to use.
The Policy Section placed all clerical and Administration staff forms on a CD for quick access. This change will cut down on administrative cost of printing forms.

XXIV. IMMUNIZATION COVERAGE ASSESSMENT
All WIC agencies are required to coordinate with and refer participants to a variety of allied nutrition and primary health care services including immunization [7 CFR 246.4(a)(8)]. As with all program coordination efforts, the method by which WIC and immunization services are coordinated is a local agency decision. The Georgia WIC Program and the Immunization Program have a signed agreement to work together to improve the immunization coverage among WIC participants. The objective of this agreement is to raise the level of immunization compliance for infants and children zero (0) to thirty-six (36) months of age. Screening for immunization status begins at two months of age. Currently there are no required immunizations for an infant younger than (2) months old. Hospital certifications are not required to screen for immunization if an assessment is done on an infant younger than two months.
WIC is under federal mandate to screen every child for immunization status at each certification. The immunization status must be recorded in the medical record and/or the computer. The following information must be recorded: Is there a documented immunization record; the response is (Y) for yes an immunization record is viewed or (R) for the record requested (record was not available). If the prior response was (Y), then the next response should be (Y) the child is adequate for age or (D) referred to doctor or (H) referred to health department. Clients who fail to bring immunization records to clinic for two (2) consecutive certification visits must be referred to the district immunization coordinator or designee for tracking and follow-up. Local agencies will be routinely monitored to assure immunization records are assessed and that referrals are being made according to local agency policy. See the Monitoring Section for the tool on which the local agency will be reviewed.

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XXV. COMPLAINT PROCEDURES
A. Procedures for processing a complaint or incident
It is required that all complaints be systematically documented. Every effort should be made to resolve an incident or complaint within twentyfour hours. (Attachment CT-39) should be used to assure that all required information is captured.
Complete the top left hand portion of the form. This section will capture the District/Unit/Clinic and the county in which the incident occurred. Complete the date of the incident and the date the incident was reported. The follow-up date will be completed later when follow-up is done. If the complaint is identified as a Civil Rights Complaint, refer immediately to the Georgia WIC Program Civil Rights Coordinator. The top right hand portion of the form is designed to capture the type of complaint. If a participant files a complaint, check participant and complete the Person Filing Complaint and Participant Information section. Proceed with the complaint. If a vendor calls with a complaint, check vendor and complete the Vendor Information section on the form and document the complaint. When recording the incident/complaint, get as much information about the situation as possible. In the absence of electronic signatures type the name of the person taking the incident/complaint. It is necessary for the local agency to document the resolution of the incident/complaint and indicate if the complaint can be closed at the local level. Record the name and title of the person resolving the complaint and the date of the resolution.
If it is necessary for the incident/complaint to be forwarded to the Georgia WIC Program the above procedure will apply for state staff. The name of the Georgia WIC Program Customer Service Coordinator or designee and date of follow-up must be documented. This form will be kept on file for three years and the current year.
B. How to file a complaint (Flyer)
It is required that the "How to File a Complaint" Flyer (Attachment CT40) be displayed and visible from all WIC Service Delivery points in the clinic. This flyer must be offered to all applicants/participants at initial certification and re-certification. Please refer to RO-6 and RO-7 regarding complaint procedures.

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XXVI. SPECIAL CERTIFICATION CONDITIONS (HOME VISITS)
A. General
A home certification may be done for WIC clients unable to visit the clinic for an extended period of time due to the following conditions: Recent child birth, prenatal on bed rest, disabilities that inhibit movement from place to place, medical equipment that is difficult to transport or health conditions that would be exacerbated by coming into a WIC clinic.
Districts must receive approval from the Georgia WIC Program as mandated by federal regulations prior to implementing the routine practice of Home Certifications. Charges for in home WIC services are forbidden.
B. Certification for Home Visits
Certification requires all information to be completed on the Certification form and vouchers issued at the time of certification in order to complete the process.
When only one person completes a certification, a copy of the completed certification form, voucher receipt(s) and any other documentation must be submitted to the WIC Coordinator or their designee within 48 hours of certification to comply with separation of duties. A form has been created to document Separation of Duties (Attachment CT-43). The Separation of Duties form must be:
x Maintained on file at the District office for review. x Maintained on file for (3) three years plus current. x Completed within 48 hours of certification.
C. Procedures
When making a home visit to certify all applicants for the program, the following procedures must be followed: 1. Staff will communicate with client by phone; obtain as much
information over the phone as possible (Establish time and date of visit).
2. Clinic staff must take a laptop or paper Certification form to the client's home. Clinic staff must request ID, residency and income

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and documents using established codes. When using a paper Certification form, place the signed copy of the form in the patients file. The certifying information must be entered into the computer. However the unsigned computer printout must not be included in the patient record.
3. VPOD vouchers must be created prior to leaving the clinic. The client then signs the voucher receipt or voucher register if blank manual vouchers are used. The signed receipt or register must be filed and maintained according to standard operating procedures.
4. Clinic staff may use the mothers Medicaid Number as proof for the first 60 days to place an infant on the Georgia WIC Program. Medicaid card verification must be done or a Thirty-Day certification may be used. If the Thirty-Day certification is used, the established procedures must be followed.
5. An Ineligibility Notice must be issued if the client is determined to be ineligible at that time.
6. If the applicant/participant is eligible after completing the certification process, Voter Registration is offered, Rights and Obligations are given, vouchers and an ID card must be issued.
7. Clinic staff must return the Certification form, signed copies of blank manual vouchers and other paperwork to clinic for filing.
8. Clinic staff must enter the information into the computer and mail copies of the blank manual vouchers (if used) to Covansys.
9. Nutrition assessment/education Based on the data collected from the WIC Assessment and Certification forms (e.g. client's available anthropometric, biochemical, nutritional information and health history), a nutrition assessment shall be done and nutrition counseling provided. The client-centered counseling shall include information on the patient's nutritional risks identified, food package prescribed, information about the program and any referrals for services needed. The nutrition education and related forms shall be documented and filed in the participant's chart upon return to the clinic.

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XXVII. SPECIAL CERTIFICATION CONDITIONS (HOSPITAL CERTIFICATION)
A. General
The certification process for Newborn/Postpartum certification in the hospital is listed below. This includes but is not limited to the certification and transfer process of WIC participants statewide. Hospital newborns/Postpartum WIC Clinics may be transit or stationary clinic sites. The hospital clinics presently serve:
x Newborns delivered on site x Postpartum women x Postpartum women already served by clinics during their prenatal
period
B. Certification procedure (with use of medical records)
When only one person completes a certification, a copy of the completed Certification form, voucher receipt(s) and any other documentation must be submitted to the WIC Coordinator or their designee within 48 hours of certification to comply with separation of duties. A form has been created to document Separation of Duties (Attachment CT-43). The Separation of Duties log must be:
x Maintained on file at the District office for review. x Maintained on file for three (3) year plus current. x Completed within 48 hours of certification.
The procedures for certification at a hospital (with permission to use Medical records) are as follows:
x A list of daily deliveries is given to WIC Staff to make rounds on the OB wards.
x WIC staff visits the OB ward and review the medical records, nurse kardex/a list and lab data, which facilitate the certification process.
x The medical records contain the identification (ID), residency, Medicaid documentation, weight, heights and hemoglobin.
x A certification form is completed. Voter Registration is offered, Rights and Obligation are given and one to three months of vouchers are issued depending on client risk and follow-up needed.
x The participant is transferred to the clinic of their choice. This includes all Health Districts and the two contracted agencies.
x Vouchers are taken on the ward stored in a locked container until

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issued. x The participant is given a follow-up appointment with the name
and phone number of the clinic to contact. x WIC staff maintains a daily running list of patients enrolled on the
program to ensure that duplication does not occur.
Note: High-risk participants Certifying staff must use professional judgment in determining the number of months of vouchers that are issued to high-risk participants.
C. Certification Procedures (without use of the Medical Record)
When only one person completes a certification, a copy of the completed Certification form, voucher receipt(s) and any other documentation must be submitted to the Nutrition Services Director or their designee within 48 hours of certification to comply with separation of duties.
The procedures for certification at a hospital without permission to use Medical Records are as follows:
x WIC staff is given a list (daily) of patients that are on the OB ward. This list contains information that will determine the status of each patient (i.e. Name, age, lab data etc. that facilitates the certification process).
x This list may also contain the identification (ID), residency, Medicaid documentation, weight, heights and hemoglobin.
x Identification, residency and income information (if adjunctive eligibility documentation is not found) is brought to the hospital or the Thirty-Day procedure should be used).
x The WIC employee verifies the list prior to making rounds on the on the OB wards. This will determine if the patient needs to be seen. Additionally, information must be asked of the applicant to determine eligibility (i.e. Income etc.).
x WIC staff maintains a daily running list of patients enrolled on the program to ensure that duplication does not occur.
x A Certification form is completed. Voter Registration is offered, Rights and Obligations are given and one to three months of vouchers are issued.
x The participant is transferred to the clinic of their choice. This includes all county clinics and the two contracted agencies.
x Vouchers are taken on the ward stored in a locked container until issued.
x The participant is given a follow-up appointment with the name

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and phone number of the clinic to contact. Note: High-risk participants Certifying staff must use professional
judgment in determining the number months of vouchers that are issued to high-risk participants.
D. 90 Day Blood Work Policy
Each District must develop a written procedure to be used in obtaining blood work on postpartum breastfeeding and non-breastfeeding women certified in the hospital. This procedure must be approved by the Office of Nutrition prior to implementation. Written approval must be kept on file in the District Office.
E. Voter Registration Policy
Applicants/participants are offered the opportunity to register to vote. A Voter Registration application is given to individuals that want to register; this form is collected and mailed to the Secretary of State's Office. It is a requirement that batch forms are completed and mailed to the Secretary of State's Office at least once a week. Files of declination statements are maintained for monitoring purposes (See the Rights and Obligation Section).
F. Transfers/Caseload Count
Hospital clinics must not maintain any WIC participant from another district more than three months. In fact, all participants certified for the program must be given a copy of their Certification form to enroll into the clinic/county of their choice
When clinic staff completes the certification documentation, the information is entered into the computer and transmitted daily to the State Contractor.
VOC cards are one method of transfers that are being used. Other clinics are using the three-ply certification form maintaining one copy for the clinic; the second copy is mailed to the receiving clinic and the third copy is given to the participant to carry to the clinic.
G. Identification (ID) Number Assignment
WIC participant ID numbers are assigned based on District policy.

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H. Thirty-Day Policy
The Thirty-Day Policy may be used in the hospital. However, only one month of vouchers may be issued and the receiving clinic must collect the missing documentation. Please remember to identify the missing documentation on the WIC ID card. Send a copy of the Thirty-Day form along with a copy of the Certification form to the new clinic site.
I. Agreement between the District and Hospital
All hospital-based clinics must have a Memorandum of Understanding or Agreement in place with District prior to opening. This agreement must be forwarded to the Georgia WIC Program upon approval.
J. Prior Approval
Written approval must be given by the Georgia WIC Program prior to opening any new WIC clinics (See the Administrative section of the Procedures Manual).
K. File Maintenance in the Hospital
Files for all hospital sites must be kept separate and apart from other records for audit purposes.
L. Voucher Security
All vouchers must be kept secure and follow the procedures outlined in the Procedures Manual.
M. Certification Process in the Hospital
Only one Certification form is required per certification. If a paper Certification form is used for certification, file it in the WIC record. Once the Certification information is entered into the computer, do not print an additional computer certification form.
N. Required Components of a Hospital Certification
1. The names, address and income of the WIC applicants must be
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acquired from the Medical Record or by requesting the information on site from the applicant. 2. The date of the initial contact date is the date the applicant is being certified and vouchers are issued at the hospital.
3. Physical Presence Status Answer Yes - The applicant is on site during the certification.
4. Residency Proof The documentation in the Medical Record or the documentation the applicant shows you on site may be used as proof of residency.
5. Identity Proof The documentation in the medical record or the documentation that the applicant shows you on site may be used as proof of identification.
6. Date of Certification and Date the Nutritional Risk data was taken This is the date the documentation was taken on site.
7. Height for Postpartum Women and Length Infants
Women - Breastfeeding and Non Breastfeeding Post Partum a. Use height from the prenatal certification or the hospital record. b. If no documented height is available, then use a selfreported height.
Infants Use birth length from the hospital for infants (in Medical Record or on the crib card).
8. Weight for Postpartum Women and Infants
Women-Breastfeeding and Non Breastfeeding Post Partum a. Pre-Pregnancy Weight - Pre-pregnancy weight from health record; self reported if not available from record. b. Current Weight Before Delivery - Required; self reported if not available from record.
Infants Weight for Infants Use birth weight from the hospital (Medical Record or the crib card).
9. Hematological Data Document post-partum hematological

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data when available or use the 90 day hematological policy.
Blood work may be available for post-partum women prior to discharge from the hospital. When postpartum breastfeeding and non-breastfeeding women are certified in the hospital, and hematological data is not available, follow these procedures: 90 Day Hematological Policy
a. Enter the Date of Certification in the Hematological Date field.
b. Enter the value 88.8 in the Hemoglobin field. c. If the applicant is assessed WIC eligible, issue up to two
months of vouchers and follow District procedures for obtaining blood work, by the next voucher issuance.
Note: Each District must develop a written procedure to be used in obtaining blood work on postpartum breastfeeding and nonbreastfeeding women certified in the hospital. This procedure must be approved by the Office of Nutrition prior to implementation. Written approval must be kept on file in the District Office.
10. Risk Factor Assessment and Documentation - The documentation may come from the Medical Record or by speaking with the WIC applicant.
Women (Breastfeeding and Non-Breastfeeding Postpartum) Evaluation of Inappropriate Nutrition Practices.
Infants a. Evaluation of Inappropriate Nutrition Practices and
completion of Growth Chart are both optional (hospitals only) b. Risk Factor Assessment Required
11. Primary Nutrition Education and Referrals - Primary nutrition education and appropriate referrals must be documented for all hospital certifications.
12. Signatures and Title of the Competent Professional Authority making the determination and Signature and title of person making income determination. Signature of the applicant/ participant/caretaker or parent Date Applicant is seen.

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13. The Statement advising participants of their Rights and Obligations while on the Program - This information is already on the Certification form.
14. If information is shared with other Programs, Disclosure Statement is required on the Certification form.
15. Notification of the participant's Rights and Obligations Must be given on site to the participant (Handout).
16. Explanation on how the Local Food Delivery System Works Must be given on site to the participant (Handout).
17. Advise in writing of the Ineligibility/Suspension or Disqualification Not necessary unless ineligible during the initial certification.
18. Voter Registration - Must be offered during the Certification period.
O. Two Types of Hospital Clinics
There are two types of Hospital Clinics. The types are listed below:
A transit clinic is a site where WIC staff does not have an office in the hospital but make rounds for eligible program applicants. Transit clinic must bring documents, vouchers, etc. to the hospital. These clinics do not store records on site. Transit clinics must have WIC records stored at a location separate and apart from other WIC records for audit purposes.
A stationary clinic is a site where WIC staff has a permanent office in the hospital. Stationary clinics have documents, vouchers, etc. housed on site. WIC records are maintained separate and apart from hospital records for WIC audit purposes.
Each site must have its own clinic number regardless if it is a stationary site or voucher issuance site. Additionally, WIC records must be attainable for audits by District/State or USDA.

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XXVIII. CLINIC STAFF RATIO
Clinic staff ratios are listed in the Administration section of the Procedures Manual for administration purposes.

XXIX. PNSS DATA COLLECTION
The Georgia WIC Program has revised the WIC certification forms (PNBIC) to incorporate the new Pregnancy Nutrition Surveillance Systems (PNSS) data collection. The new PNSS data is located on the back of the Prenatal, Breastfeeding and Non- breastfeeding Certification forms. PNSS is a program based public health surveillance system that monitors risk factors associated with infant mortality and poor birth outcomes among low-income pregnant.
The Pediatric Nutrition Surveillance System (PedNSS) is a child based public health surveillance system that subscribes the nutritional status of low income U.S. children who attend federally-funded maternal and child health and nutrition programs.

XXX. WIC INTERVIEW SCRIPT
The WIC Interview Script provides WIC applicants/participants with general WIC information. The WIC Interview Script must be presented to all WIC applicants/participants during the certification process so they will have the opportunity to select their ethnicity, migrancy status and all racial categories that applies.
The WIC Interview Script will be a part of the WIC Programmatic Review. (Attachment CT-42)

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Attachment CT-1

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Attachment CT-1 (cont'd)

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Attachment CT-2

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Attachment CT-2 (cont'd)

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Attachment CT-2 (cont'd)

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Attachment CT-3

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Attachment CT-3 (cont'd)

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Attachment CT-4

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Attachment CT-4 (cont'd)

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Attachment CT-5

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Attachment CT-5 (cont'd)

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Attachment CT-6

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
PRENATAL WOMEN

Data
Height Pre-Pregnancy Weight
Current Weight Hematocrit or Hemoglobin Prenatal Weight Grid Plotted Evaluation of Inappropriate Nutrition Practices
Risk Factor Assessment

Prenatal Women
Required Required Required Required Required Required Required

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Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA PREGNANT WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1)

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

1st Trimester (0-13 wks): Non-Smokers Smokers

Hemoglobin
10.9 gm or lower 11.2 gm or lower

2nd Trimester (14-26 wks): Non-Smokers Smokers

10.4 gm or lower 10.7 gm or lower

3rd Trimester (27-40 wks): Non-Smokers Smokers 10.9 gm or lower 11.2 gm or lower

Hematocrit
32.9% or lower 33.9% or lower
31.9% or lower 32.9% or lower
32.9% or lower 33.9% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

I

Pre-pregnancy weight is equal to a Body Mass Index (BMI) of <19.8. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI <19.8

111

OVERWEIGHT

I

Pre-pregnancy weight is equal to a Body Mass Index of >26. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI >29

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CODE

PRIORITY

131

LOW GESTATIONAL WEIGHT GAIN

I

For second (14-26 weeks) and third (27-40 weeks) trimesters, low weight gain such that a prenatal woman's weight plots at any point beneath the bottom (solid) line of the recommended weight range, on the appropriate Prenatal Weight Gain Grid.

High Risk: Low Gestational Weight Gain

132

GESTATIONAL WEIGHT LOSS DURING PREGNANCY

I

x During first (0-13 weeks) trimester, any weight loss below pregravid weight; based on pregravid weight and current weight.
OR x During second and third trimesters (14-40 weeks gestation), >2 lbs weight loss.
Based on two weight measures recorded at 14 weeks gestation or later.

Document: Two weight measures as specified above

High Risk: Weight loss of >2 lbs in the second and third trimesters

133

HIGH GESTATIONAL WEIGHT GAIN

I

Weight gain of >7 pounds/month (4.3 weeks/month)

Document: Two weight measures that are at least one month (4.3 weeks) apart (pregravid weight may be self-declared). If the two measurements are >1 month apart, calculate the average weight gain per month.

To calculate average weight gain/month, use the following equation:

current weight previous weight x 4.3 # weeks between the two weights

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CODE

211

ELEVATED BLOOD LEAD LEVELS

Blood lead level of >10 Pg/deciliter

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months.

High Risk: Blood lead level of >10 Pg/deciliter

PRIORITY I

301

HYPEREMESIS GRAVIDARUM

I

Severe nausea and vomiting to the extent that the pregnant woman becomes dehydrated and acidotic.

Presence of hyperemesis gravidarum diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record

High Risk: Diagnosed hyperemesis gravidarum

302

GESTATIONAL DIABETES

I

Presence of gestational diabetes diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, name of the physician that is treating this condition, and the current diet prescription (if provided) in the participant's health record

High Risk: Diagnosed gestational diabetes

303

HISTORY OF GESTATIONAL DIABETES

I

Any history of gestational diabetes diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Pregnancy or pregnancies when gestational diabetes was diagnosed

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CODE

311

HISTORY OF PRETERM DELIVERY

Any history of infant(s) born at 37 weeks gestation or less

Document: Delivery date(s) and weeks gestation in participant's health record

312

HISTORY OF LOW BIRTH WEIGHT INFANT(S)

Woman has delivered one (1) or more infants with a birth weight of 5 lb 8 oz (2500 gms) or less.

Document: Weight(s) and birth date(s) in the participant's health record

PRIORITY I
I

321

HISTORY OF FETAL OR NEONATAL DEATH

I

Any fetal death(s) (death >20 weeks gestation) or neonatal death(s) (death occurring from 0-28 days of life).

Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

331

PREGNANCY AT A YOUNG AGE

I

For current pregnancy, EDC at less than 18 years and 10 months of age.

Document: Expected date of delivery (EDC) on the WIC Assessment/ Certification Form

High Risk: EDC at less than 17 years of age

332

CLOSELY SPACED PREGNANCIES

I

For current pregnancy, the participant's EDC is less than 25 months after the termination of the last pregnancy.

Document: Termination date of last pregnancy and EDC in the participant's health record

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CODE 333

HIGH PARITY AND YOUNG AGE The following two (2) conditions must both apply:

PRIORITY I

1. The woman is under age 20 at date of conception, AND 2. She has had 3 or more previous pregnancies of at least 20 weeks duration,
regardless of birth outcome.

Document: EDC date; number of pertinent pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record

334

LACK OF, OR INADEQUATE PRENATAL CARE

I

Prenatal care beginning after the 1st trimester (0-13 weeks)

Document: Weeks gestation, in participant's health record, when prenatal care began. A pregnancy test is not prenatal care.

335

MULTI-FETAL GESTATION

I

For current pregnancy, the woman has more than one fetus. Must be diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of physician that is treating the participant, in the participant's health record

High Risk: Multi-fetal gestation

336

FETAL GROWTH RESTRICTION

I

Fetal Growth Restriction (FGR) must be diagnosed by a physician or a health professional acting under standing orders of a physician.

Document: Diagnosis in participant's health record

337

HISTORY OF BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

Prenatal woman has delivered one (1) or more infants with a birth weight of 9 pounds (4000 gm) or more, OR infant(s) diagnosed as large for gestational age by a physician or a health professional acting under standing orders of a physician.

Document: Birth weight(s) and/or diagnosis in the participant's health record

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CODE 338

PREGNANT WOMAN CURRENTLY BREASTFEEDING

Breastfeeding woman who is now pregnant.

Note: Refer to or provide appropriate breastfeeding counseling, especially if at risk for not meeting her own nutrient needs, for a decrease in milk supply, or for premature labor.

PRIORITY I

339

HISTORY OF BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH

DEFECT(S)

I

A prenatal woman with any history of giving birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake, e.g., inadequate zinc, folic acid (neural tube defect), excess vitamin A (cleft palate or lip).

Document: Infant(s) congenital and/or birth defect(s) in participant's health record

NUTRITION RELATED MEDICAL CONDITIONS I

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micronutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

The presence of nutrient deficiency diseases diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed nutrient deficiency disease

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Attachment CT-6 (cont'd)

CODE

PRIORITY

342

GASTRO-INTESTINAL DISORDERS:

I

Diseases or conditions that interfere with the intake or absorption of nutrients. The conditions include, but are not limited to: stomach or intestinal ulcers, liver disease, bowel enterocolitis and syndrome, pancreatitis, malabsorption syndromes, gallbladder disease, inflammatory bowel disease (including ulcerative colitis and crohn's disease).

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

343

DIABETES MELLITUS

I

Presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, name of the physician that is treating this condition, and current diet prescription (if provided) in participant's health record.

High Risk: Diagnosed diabetes mellitus

344

THYROID DISORDERS

I

Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed thyroid disorder

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

345

HYPERTENSION

I

Presence of hypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypertension

346

RENAL DISEASE

I

Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by applicant/ participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed renal disease

347

CANCER

I

The current condition, or the treatment for the condition MUST be severe enough to affect nutritional status. Presence of cancer diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed cancer

CT-106

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

349

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed genetic/congenital disorder

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

351

INBORN ERRORS OF METABOLISM

I

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed inborn error of metabolism

352

INFECTIOUS DISEASES

I

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

353

FOOD ALLERGIES

I

Presence of a food allergy diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed food allergy.

354

CELIAC DISEASE

I

Also known as celiac sprue, gluten enteropathy, or non-tropical sprue.

Presence of celiac disease diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

I

Presence of lactose intolerance diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician; OR symptoms must be well documented by the competent professional authority.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea). With list of symptoms, indicate that ingestion of dairy products causes these and avoidance of such products eliminates them.

High Risk: Lactose intolerance

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

356

HYPOGLYCEMIA

I

Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

357

DRUG/NUTRIENT INTERACTIONS

I

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

358

EATING DISORDERS

I

Presence of eating disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed eating disorder

CT-110

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

359

RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

Major surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health care provider working under the orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns within past 2 months

360

OTHER MEDICAL CONDITIONS

I

Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate, persistent or severe asthma.

Presence of other medical conditions diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care provider working under the orders of a physician.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status

361

DEPRESSION

I

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of physician that is treating this condition in the participant's health record

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

THE ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Document: Specific condition/ description of delays and how these interfere with the ability to eat and the name of the physician that is treating this condition.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

PRIORITY I

371

MATERNAL SMOKING

I

Any smoking of cigarettes, pipes or cigars.

Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

372

ALCOHOL USE

I

Any alcohol use:

A serving of standard sized drink (1 ounce of alcohol) is:

x 1 can of beer (12 fluid oz) x 5 oz wine x 1 fluid oz liquor

Binge drinking is defined as > 5 drinks on the same occasion on at least one day in the past 30 days

Heavy drinking is defined as > 5 drinks on the same occasion on five or more days in the past 30 days

Document: Enter the number of oz of alcohol/per week intake on WIC Assessment/Certification form. See Appendix E-1 for documentation codes.

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

373

STREET DRUG USE

I

Any illegal drug use. Including but not limited to: marijuana, cocaine and cocaine derivatives, heroin, amphetamines, tranquilizers, and barbiturates.

Document: Type of drug(s) being used. See Appendix E-2 for documentation codes.

381

DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to: gingivitis of pregnancy, tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

400 INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

801

HOMELESSNESS

IV

Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedure Manual.

802

MIGRANCY

IV

Migrancy as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

901

RECIPIENT OF ABUSE

IV Battering (abuse) within past 6 months as self-reported, or as documented by a social worker, health care provider or on other appropriate documents, or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Battering refers to violent assaults on women.

902

PRENATAL WOMAN WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

x mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
x physical disability which restricts or limits food preparation abilities x current use of or history of abusing alcohol or other drugs

Document: The women's specific limited abilities in the participant's health record.

502

TRANSFER OF CERTIFICATION

I, IV

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion should be used primarily when the VOC card/document does not reflect another more specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving agency.

401

OTHER DIETARY RISK (FAILURE TO MEET DIETARY GUIDELINES)

IV

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk

CT-114

GA WIC 2010 PROCEDURES MANUAL
400 or for any other risk factor.)

Attachment CT-6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
BREASTFEEDING WOMEN

Data
Height
Pre-Pregnancy Weight
Current Weight Last Weight Before Delivery Hemoglobin or Hematocrit Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Breastfeeding and Non-Breastfeeding Woman Certified in Hospital Prior to Initial Discharge
Pre-pregnancy height from health record; self reported if not available from record
Pre-pregnancy weight from health record; self reported if not available from record
If available

Woman Certified in Clinic
Required
Required Required

Breastfeeding Woman Certified in
Clinic >6 Months Postpartum
Required
Required
Required

Required

Required

Required

Required (Apply 90-day rule when not available)

Required

Optional

Required

Required

Required

Required

Required

Required

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA BREASTFEEDING WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification

(See Appendix A-1)

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

Non-Smokers: Smokers:

Hemoglobin: Hematocrit: Hemoglobin: Hematocrit:

11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age) 35.8% or lower
12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age) 36.8% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

I

< 6 months Postpartum: Pre-pregnancy or current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-2.

High Risk: Pre-pregnancy or current BMI <18.5

6 months Postpartum: Current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-2.

High Risk: Current BMI <18.5

111

OVERWEIGHT

I

<6 months Postpartum: Pre-pregnancy weight is equal to a Body Mass Index (BMI) of >24.9. Refer to BMI Table, Appendix C-2.

High Risk: Pre-pregnancy BMI >29.9

6 months Postpartum: Current weight is equal to a Body Mass Index (BMI) of >24.9. Refer to BMI Table, Appendix C-2.

High Risk: Current BMI >29.9

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

133

HIGH GESTATIONAL WEIGHT GAIN

I

Total gestational weight gain exceeds the upper limit of the recommended range based on pre-pregnancy weight for height OR pre-pregnancy BMI. Applies to most recent pregnancy only.

Pre-pregnancy Weight Group

Cut-off Value

Underweight Normal Weight Overweight Obese

>40 lbs >35 lbs >25 lbs >15 lbs

Multi-Fetal Pregnancy: There are no nationally recognized recommendations for upper limit for multi-fetal gestations at this time.

Document: Pre-gravid weight and last weight before delivery

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 Pg/deciliter

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months.

High Risk: Blood lead level of >10 Pg/deciliter

303

GESTATIONAL DIABETES (MOST RECENT PREGNANCY)

I

Presence of gestational diabetes, during most recent pregnancy, diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician. Applies to most recent pregnancy only.

Document: Diagnosis in the participant's health record

311

DELIVERY OF PREMATURE INFANT(S)

I

Woman has delivered one (1) or more infants at 37 weeks gestation or less. Applies to most recent pregnancy only.

Document: Delivery date and weeks gestation in participant's health record

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

312

DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

I

Woman has delivered one (1) or more infants with a birth weight of 5 lb 8 oz (2500 gms) or less. Applies to most recent pregnancy only.

Document: Weight(s) and birth date in the participant's health record

321

FETAL OR NEONATAL DEATH

I

A fetal death (death > 20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy only.

Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

331

PREGNANCY AT A YOUNG AGE

I

For most recent pregnancy, delivery date at less than 18 years and 10 months of age. Applies to most recent pregnancy only.

Document: Delivery date on the WIC Assessment/Certification Form

High Risk: Delivery date at less than 17 years of age

332

CLOSELY SPACED PREGNANCIES

I

Delivery date for most recent pregnancy occurred less than 25 months after the termination of the previous pregnancy.

Document: Termination dates of last two pregnancies in the participant's health record.

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

333

HIGH PARITY AND YOUNG AGE

I

The following two (2) conditions must both apply:

1. The woman is under age 20 at date of conception AND

2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy.

Document: Delivery date; number of pertinent previous pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record

335

MULTI FETAL GESTATION

I

Had greater than one fetus in most recent pregnancy.

High Risk: Multi-fetal gestation

337 HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

I

Birth of an infant with a birth weight of 9 pounds or more, OR infant diagnosed as large for gestational age by a physician or a health professional acting under orders of a physician.

Document: Birth weight(s) and/or diagnosis in the participant's health record.

339

BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S)

I

A woman who gives birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake, e.g., inadequate zinc, folic acid (neural tube defect), excess vitamin A (cleft palate or lip). Applies to most recent pregnancy only.

Document: Infant(s) congenital and/or birth defect(s) in participant's health record

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

NUTRITION RELATED MEDICAL CONDITIONS

I

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

The presence of nutrient deficiency diseases diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed nutrient deficiency disease

342

GASTRO-INTESTINAL DISORDERS

I

Diseases or conditions that interfere with the intake or absorption of nutrients. The conditions include, but are not limited to: stomach or intestinal ulcers, liver disease, bowel enterocolitis and syndrome, pancreatitis, malabsorption syndromes, gallbladder disease, inflammatory bowel disease (including ulcerative colitis and crohn's disease).

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

CT-120

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

343

DIABETES MELLITUS

Presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, name of the physician that is treating this condition and current diet prescription (if provided) in the participant's health record.

High Risk: Diagnosed diabetes mellitus

PRIORITY I

344

THYROID DISORDERS

I

Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

I

Presence of hypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed hypertension

CT-121

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

346

RENAL DISEASE

I

Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by applicant/ participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed renal disease

347

CANCER

I

The current condition, or the treatment for the condition MUST be severe enough to affect nutritional status. Presence of cancer diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating the condition in the participant's health record.

High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

Conditions which affect energy requirements and may affect the individual's ability to feed self that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed central nervous system disorder

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

349

GENETIC AND CONGENITAL DISORDERS

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed genetic/congenital disorder

PRIORITY I

351

INBORN ERRORS OF METABOLISM

I

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed inborn error of metabolism

CT-123

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

352

INFECTIOUS DISEASES

I

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating this condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above

353

FOOD ALLERGIES

I

Presence of a food allergy diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed food allergy

354

CELIAC DISEASE

I

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac disease diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed Celiac Disease

CT-124

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

355

LACTOSE INTOLERANCE

I

Presence of lactose intolerance diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician; OR symptoms must be well documented by the competent professional authority.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea). With list of symptoms, indicate that ingestion of dairy products causes these and avoidance of such products eliminates them.

High Risk: Lactose intolerance

356

HYPOGLYCEMIA

I

Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

357

DRUG/NUTRIENT INTERACTIONS

I

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

CT-125

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

358

EATING DISORDERS

Presence of eating disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed eating disorder

PRIORITY I

359

RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

Major surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under the standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns within the past 2 months

CT-126

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

360

OTHER MEDICAL CONDITIONS

I

Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate persistent or severe asthma.

Presence of other medical conditions diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care provider working under the standing orders of a physician.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status

361

DEPRESSION

I

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

I

ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Document: Specific condition/description of the delay and how it interferes with the ability to eat and the name of the physician that is treating this condition in the participant's health record.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

CT-127

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

371

MATERNAL SMOKING

I

Any smoking of cigarettes, pipes or cigars.

Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification form.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

372

ALCOHOL USE

I

Routine current use of > 2 drinks per day OR binge drinking OR heavy drinking

A serving of standard sized drink (1 ounce of alcohol) is: x 1 can of beer (12 fluid oz) x 5 oz wine x 1 fluid oz liquor, OR

Binge drinking is defined as >5 drinks on the same occasion on at least one day in the past 30 days, OR

Heavy drinking is defined as >5 drinks on the same occasion on five or more days in the past 30 days

Document: Enter the number of oz of alcohol/week intake on WIC Assessment/Certification form. See Appendix E-1 for documentation codes.

373

STREET DRUG USE

I

Any illegal drug use. Including but not limited to: marijuana, cocaine and cocaine derivatives, heroin, amphetamines, tranquilizers, and barbiturates.

Document: Type of drug(s) being used. See Appendix E-2 for documentation codes.

CT-128

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

381

DENTAL PROBLEMS

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to: tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

PRIORITY I

400

INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or
health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

601

BREASTFEEDING AN INFANT AT NUTRITIONAL RISK

A breastfeeding woman whose breastfed infant has been determined to be at nutritional risk.

Document: Infant's risks on mother's WIC Assessment/Certification form.

I, II, IV

CT-129

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

602

BREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS

A breastfeeding woman with any of the following complications or potential complications for breastfeeding.

a. severe breast engorgement b. recurrent plugged ducts c. mastitis d. flat or inverted nipples e. cracked, bleeding or severely sore nipples f. age > 40 years g. failure of milk to come in by 4 days postpartum h. tandem nursing (nursing two siblings who are not twins)

Document: Complications or potential complications in the participant's health record.

High Risk: Refer to or provide the mother with appropriate breastfeeding counseling.

801

HOMELESSNESS

Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

PRIORITY I
IV

802

MIGRANCY

IV

Migrancy as defined in the Special Population Section of the Georgia WIC Program Procedures Manual.

901

RECIPIENT OF ABUSE

IV

Battering within past 6 months as self-reported, or as documented by a social worker,

health care provider or on other appropriate documents, or as reported through

consultation with a social worker, health care provider or other appropriate personnel.

Battering refers to violent assaults on women.

CT-130

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

902 BREASTFEEDING WOMAN WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

x mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
x physical disability which restricts or limits food preparation abilities x current use of or history of abusing alcohol or other drugs

Document: The women's specific limited abilities in the participant's health record.

502

TRANSFER OF CERTIFICATION

I, II, IV

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion should be used primarily when the VOC card/document does not reflect another more specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving agency.

401

OTHER DIETARY RISK (FAILURE TO MEET DIETARY GUIDELINES)

IV

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

CT-131

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
POSTPARTUM NON-BREASTFEEDING WOMEN

Data
Height
Pre-Pregnancy Weight Current Weight Last Weight Before Delivery Hemoglobin or Hematocrit Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Woman Certified in Hospital Prior to Initial
Discharge
Pre-pregnancy height from health record; self reported if
not available from record
Pre-pregnancy weight from health record; self reported if
not available from record
If available
Required
Required (Apply 90-day rule when not
available)
Required
Required

Woman Certified in Clinic
Required
Required Required Required Required
Required Required

CT-132

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA POSTPARTUM, NON- BREASTFEEDING WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1)

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

VI

Non-Smokers:

Hemoglobin: Hematocrit:

11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age)
35.8% or lower

Smokers:

Hemoglobin: Hematocrit:

12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age)
36.8% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

VI

Pre-pregnancy or current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-2.

High Risk: Pre-pregnancy or current BMI <18.5

111

OVERWEIGHT

VI

Pre-pregnancy weight is equal to a Body Mass Index (BMI) of >24.9. Refer to BMI Table, Appendix C-2.

High Risk: Pre-pregnancy BMI >29.9

CT-133

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

133

HIGH GESTATIONAL WEIGHT GAIN

VI

Total gestational weight gain exceeds the upper limit of the recommended range based on pre-pregnancy weight for height OR pre-pregnancy BMI. Applies to most recent pregnancy only.

Pre-pregnancy Weight Group

Cut-off Value

Underweight Normal Weight Overweight Obese

>40 lbs >35 lbs >25 lbs >15 lbs

Multi-Fetal Pregnancy: There are no nationally recognized recommendations for upper limit for multi-fetal gestations at this time.
Document: Pre-gravid weight and last weight before delivery

211

ELEVATED BLOOD LEAD LEVELS

VI

Blood lead level of >10 Pg/deciliter

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months.

High Risk: Blood lead level of >10 Pg/deciliter

303

GESTATIONAL DIABETES (MOST RECENT PREGNANCY)

VI

Presence of gestational diabetes, during most recent pregnancy, diagnosed by a physician as self reported by applicant/ participant/ caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician. Applies to most recent pregnancy only.

Document: Diagnosis in the participant's health record

311

DELIVERY OF PREMATURE INFANT(S)

VI

Woman has delivered one (1) or more infants at 37 weeks gestation or less. Applies to most recent pregnancy only.

Document: Delivery date and weeks gestation in participant's health record

CT-134

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

312

DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

Woman has delivered one (1) or more infants with a birth weight of 5 lb 8 oz (2500 gms) or less. Applies to most recent pregnancy only.

Document: Weight(s) and birth date in the participant's health record.

PRIORITY VI

321

FETAL OR NEONATAL DEATH

VI

A fetal death (death > 20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy only.

Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

331

PREGNANCY AT A YOUNG AGE

III

For most recent pregnancy, delivery date at less than 18 years and 10 months of age. Applies to most recent pregnancy only.

Document: Delivery date on the WIC Assessment/Certification Form

High Risk: Delivery date at less than 17 years of age

332

CLOSELY SPACED PREGNANCIES

Delivery date for most recent pregnancy occurred less than 25 months after the

VI

termination of the previous pregnancy.

Document: Termination dates of last two pregnancies in the participant's health record.

CT-135

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

333

HIGH PARITY AND YOUNG AGE

The following two (2) conditions must both apply:

1. The woman is under age 20 at date of conception AND

2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy.

Document: Delivery date; number of pertinent previous pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record

335

MULTI FETAL GESTATION

Had greater than one fetus in most recent pregnancy.

High Risk: Multi-fetal gestation

PRIORITY VI
VI

337

HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

VI

Birth of an infant with a birth weight of 9 pounds or more, OR infant diagnosed as large for gestational age by a physician or a health professional acting under standing orders of a physician.
Document: Birth weight(s) and/or diagnosis in the participant's health record.

339

BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S)

VI

A woman who gives birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake, e.g., inadequate zinc, folic acid (neural tube defect) , excess vitamin A (cleft palate or lip). Applies to most recent pregnancy only.

Document: Infant(s) congenital and/or birth defect(s) in the participant's health record.

CT-136

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

NUTRITION RELATED MEDICAL CONDITIONS

VI

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

The presence of nutrient deficiency diseases diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed nutrient deficiency disease

342

GASTRO-INTESTINAL DISORDERS

VI

Diseases or conditions that interfere with the intake or absorption of nutrients. The conditions include, but are not limited to: stomach or intestinal ulcers, liver disease, bowel enterocolitis and syndrome, pancreatitis, malabsorption syndromes, gallbladder disease, inflammatory bowel disease (including ulcerative colitis and crohn's disease).

The presence of a gastro-intestinal disorder diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

CT-137

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

343

DIABETES MELLITUS

Presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, name of the physician that is treating this condition, and
current diet prescription (if provided) in the participant's health record.

High Risk: Diagnosed diabetes mellitus

PRIORITY VI

344

THYROID DISORDERS

VI

Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a physician as self reported by applicant/participant/ caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

VI

Presence of hypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed hypertension

CT-138

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

346

RENAL DISEASE

VI

Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed renal disease

347

CANCER

VI

The current condition, or the treatment for the condition MUST be severe enough to affect nutritional status. Presence of cancer diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed cancer

CT-139

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

348

CENTRAL NERVOUS SYSTEM DISORDERS

VI

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of central nervous system disorder(s) diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed central nervous system disorder

349

GENETIC AND CONGENITAL DISORDERS

VI

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed genetic/congenital disorder

CT-140

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

351

INBORN ERRORS OF METABOLISM

VI

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethionninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed inborn error of metabolism

352

INFECTIOUS DISEASES

VI

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by applicant/participant/ caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above

CT-141

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

353

FOOD ALLERGIES

Presence of a food allergy diagnosed by a physician, as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition. High Risk: Diagnosed food allergy

PRIORITY VI

354

CELIAC DISEASE

VI

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac disease diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition.

High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

VI

Presence of lactose intolerance diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician; OR symptoms must be well documented by the competent professional authority.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea). With list of symptoms, indicate that ingestion of dairy products causes these and avoidance of such products eliminates them.

High Risk: Lactose intolerance

CT-142

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

356

HYPOGLYCEMIA

VI

Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

357

DRUG/NUTRIENT INTERACTIONS

VI

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

358

EATING DISORDERS

VI

Presence of eating disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition.

High Risk: Diagnosed eating disorder

CT-143

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

359

RECENT MAJOR SURGERY, TRAUMA OR BURNS

VI

Major surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health care provider working under the standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns within the past 2 months.

360

OTHER MEDICAL CONDITIONS

VI

Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate persistent or severe asthma.

Presence of other medical conditions diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care provider working under the standing orders of a physician.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status

CT-144

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

361

DEPRESSION

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

PRIORITY VI

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH THE

VI

ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Document: Specific condition/ description of delays and how these interfere with the ability to eat and the name of the physician that is treating this condition.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

371

MATERNAL SMOKING

VI

Any smoking of cigarettes, pipes or cigars.
Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification form.

904 ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

VI

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-145

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

372

ALCOHOL USE

VI

Routine current use of > 2 drinks per day OR binge drinking OR heavy drinking

A serving of standard sized drink (1 ounce of alcohol) is: x 1 can of beer (12 fluid oz) x 5 oz wine x 1 fluid oz liquor, OR

Binge drinking is defined as >5 drinks on the same occasion on at least one day in the past 30 days, OR

Heavy drinking is defined as >5 drinks on the same occasion on five or more days in the past 30 days

Document: Enter the number of oz of alcohol/per week intake on WIC Assessment/Certification form. See Appendix E-1 for documentation codes.

373

STREET DRUG USE

VI

Any illegal drug use. Including but not limited to: marijuana, cocaine and cocaine derivatives, heroin, amphetamines, tranquilizers, and barbiturates.

Document: Type of drug(s) being used. See Appendix E-2 for documentation codes.

381

DENTAL PROBLEMS

VI

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to: tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

CT-146

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

400

INAPPROPRIATE NUTRITION PRACTICES

VI

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

801

HOMELESSNESS

VI

Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

802

MIGRANCY

VI

Migrancy as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

901

RECIPIENT OF ABUSE

VI

Battering within past 6 months as self-reported, or as documented by a social worker, health care provider or on other appropriate documents, or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Battering refers to violent assaults on women.

902

POSTPARTUM, NON-BREASTFEEDING WOMAN WITH LIMITED

IV

ABILITY TO MAKE FEEDING DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

x mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
x physical disability which restricts or limits food preparation abilities x current use of or history of abusing alcohol or other drugs

Document: The women's specific limited abilities in the participant's health record.

CT-147

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

502

TRANSFER OF CERTIFICATION

III, VI

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion should be used primarily when the VOC card/document does not reflect another more specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving agency.

401

OTHER DIETARY RISK (FAILURE TO MEET DIETARY GUIDELINES)

VI

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

CT-148

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Data
Length
Weight
Hematocrit or Hemoglobin
Weight for Age Plotted
Length for Age Plotted
Weight for Length Plotted
Evaluation of Inappropriate Nutrition Practices
Risk Factor Assessment

Infant Certified in Hospital Prior to Initial Discharge
Birth Data or other measurement
Birth Data or other measurement

Documentation Infant 0-6 Months
Required
Required

N/A

Optional

Optional

Required

Infant 6-12 Months
Required
Required Required (9-12 months)
Required

Optional

Required

Required

Optional

Required

Required

Optional Required

Required Required

Required Required

CT-149

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA INFANTS

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification

(See Appendix A-2)

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

Hemoglobin: 10.9 gm or lower (6-11 month old) Hematocrit: 32.8% or lower (6-11 month old)

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-2)

103

UNDERWEIGHT

I

Less than or equal to the 10th percentile weight for length, based on the Centers for Disease Control and Prevention (CDC) age/sex specific growth charts.

High Risk: Weight for length < 5th percentile

121

SHORT STATURE

I

Less than or equal to the 10th percentile length for age based on CDC age/sex specific

growth charts. (if < 38 weeks gestation use adjusted age)

High Risk: Length for age < 5th percentile

134

FAILURE TO THRIVE

I

Presence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician.

Document: Diagnosis in the participant's health record

High Risk: Diagnosed failure to thrive

CT-150

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

135

INADEQUATE GROWTH

I

An inadequate rate of weight gain as defined below:

Infants being certified during period from birth to 1 month of age:

Not back to birth weight by 2 weeks of age A gain of less than 19 ounces by 1 month of age

Infants being certified during period from 1 to 5 months of age:

This method (explained in Appendix C-3) is optional, if an infant 1 to 5 months of age qualifies for WIC based on any other risk criterion. If there is no other reason to qualify the infant, use this method to determine eligibility.

Infants 6 months to 12 months of age:

Age in Months at Certification

Weight Gain per 6-month interval*

5 mos - 6 mos >6 mos - 9 mos >9 mos - 12 mos

< 7 lbs < 5 lbs
< 3 lbs

*Note: Use this chart only for infants who are > 5 months 2 weeks of age. Use only for an interval of 6 months +/- 2 weeks.

High Risk: Inadequate growth

141

LOW BIRTH WEIGHT

I Birth weight < 5 lbs 8 oz (< 2500 g)

Document: Birth weight in participant's health record

High Risk: Birth weight < 5 lbs 8 oz (< 2500 g)

CT-151

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

142

PREMATURITY

Infant born at < 37 weeks gestation

Document: Weeks gestation in participant's health record

PRIORITY I

153

LARGE FOR GESTATIONAL AGE

I

Birth weight > 9 lbs or presence of large for gestational age diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care professional working under standing orders of a physician.

Document: Weight(s) of infant in participant's health record.

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of > 10 Pg/deciliter.

Document: Date of blood test and blood lead level in participant's health record. Must be within the past 6 months

High Risk: Blood lead level of > 10 Pg/deciliter

CT-152

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

PRIORITY I

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

Presence of nutrient deficiency diseases diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record

High Risk: Diagnosed nutrient deficiency disease

342

GASTRO-INTESTINAL DISORDERS

I

Diseases or conditions that interfere with the intake or absorption of nutrients. The conditions include, but are not limited to: stomach or intestinal ulcers, liver disease, bowel enterocolitis and syndrome, pancreatitis, malabsorption syndromes, gallbladder disease, inflammatory bowel disease (including ulcerative colitis and crohn's disease).

Presence of gastro-intestinal disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

CT-153

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

343

DIABETES MELLITUS

I

Presence of diabetes mellitus diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis, name of the physician that is treating condition and current diet prescription (if provided) in participant's health record.

High Risk: Diagnosed diabetes mellitus

344

THYROID DISORDERS

I

Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

I

Presence of hypertension diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypertension

CT-154

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

346

RENAL DISEASE

I

Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed renal disease

347

CANCER

I

The current condition, or the treatment for the condition MUST be severe enough to affect nutritional status. Presence of cancer diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebal palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

CT-155

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed genetic and congenital disorder

350

PYLORIC STENOSIS

I

Gastrointestinal obstruction with abnormal gastrointestinal function affecting nutritional status.

Presence of pyloric stenosis dignosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed pyloric stenosis

CT-156

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

351

INBORN ERRORS OF METABOLISM

I

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed inborn error of metabolism

352

INFECTIOUS DISEASES

I

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above.

CT-157

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

353

FOOD ALLERGIES

I

Presence of a food allergy diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed food allergy

354

CELIAC DISEASE

I

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac disease diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

I

Presence of lactose intolerance diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician; OR symptoms described by caregiver must be well documented by the competent professional authority

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record; OR list of symptoms described by caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea). With list of symptoms, indicate that ingestion of lactose-containing foods/dairy products causes these and avoidance of such foods/products eliminates them.

High Risk: Lactose intolerance

CT-158

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

356

HYPOGLYCEMIA

I

Presence of hypoglycemia diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypoglycemia

357

DRUG/NUTRIENT INTERACTIONS

I

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

359

RECENT MAJOR SURGERY, TRAUMA, BURNS

I

Major surgery, trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported, by caregiver. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affect nutritional status and include date.

High Risk: Major surgery, trauma or burns within the past 2 months.

CT-159

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

360

OTHER MEDICAL CONDITIONS

I

Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate persistent or severe asthma.

Presence of other medical conditions diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status.

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

I

ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Presence of developmental, sensory or motor delay diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Specific condition/ description of delays and how these interfere with the ability to eat and the name of the physician that is treating this condition.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

CT-160

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

381

DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to:

x Presence of nursing bottle caries x Smooth surface decay of the maxillary anterior and the primary molars

Document: Description of how the dental problem interferes with mastication and/or has other nutritionally related health problems in the participant's health record.

382

FETAL ALCOHOL SYNDROME

I

Fetal Alcohol Syndrome (FAS) is based on the presence of retarded growth, a pattern of facial abnormalities and abnormalities of the central nervous system, including mental retardation.

Presence of FAS diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of physician treating the condition in the participant's health record.

High Risk: Diagnosed fetal alcohol syndrome

400

INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)
Document: Inappropriate Nutrition Practice(s) in the participant's health record.

CT-161

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

603

BREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS

I

Any of the following are considered complications or potential complications of breastfeeding:

x Breastfed infant with jaundice x Breastfed infant with weak or ineffective suck x Breastfed infant with difficulty latching onto mother's breast x Breastfed infant with inadequate stooling for age (as determined by a physician or
other health care provider) x Breastfed infant who wets diaper less than 6 times per day

Document: Complications or potential complications in the participant's health record.

High Risk: Refer to or provide the infant's mother with appropriate breastfeeding counseling.

701

INFANT UP TO 6 MONTHS OLD OF WIC MOTHER, OR OF A WOMAN WHO

II

WOULD HAVE BEEN ELIGIBLE DURING PREGNANCY

x An infant under 6 months of age whose mother was a WIC Program participant during pregnancy, OR
x An infant whose mother's medical records document that the woman was at nutritional risk during pregnancy because of detrimental or abnormal nutrition conditions detectable by biochemical or anthropometric measurements or other
documented nutritionally related medical conditions.

702

BREASTFEEDING INFANT OF A WOMAN AT NUTRITIONAL RISK

A breastfed infant whose breastfeeding mother has been determined to be at nutritional risk.

Document: Mother's risks on infant's WIC Assessment/Certification form

I, II, IV

CT-162

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

703

INFANT BORN TO MOTHER WITH MENTAL RETARDATION, OR

ALCOHOL OR DRUG ABUSE DURING MOST RECENT PREGNANCY

x Infant born of a woman diagnosed with mental retardation by a physician or psychologist as self-reported by caregiver; or as reported by a physician, psychologist, or someone working under physician's orders; OR
x Documentation or self-report of any use of alcohol or illegal drugs during most recent pregnancy.

PRIORITY I

801

HOMELESSNESS

IV Homelessness as defined in the Special Population Section of the Georgia WIC Procedures Manual.

802

MIGRANCY

IV

Migrancy as defined in the Special Population Section of the Georgia WIC Procedures Manual.

CT-163

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

901

RECIPIENT OF ABUSE

IV Child abuse/neglect within past 6 months as self-reported by the caregiver, or as documented by a social worker, health care provider or on other appropriate documents, or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Child abuse/neglect refers to any recent act, or failure to act, resulting in:

x Imminent risk or serious harm x Serious physical or emotional harm x Sexual abuse or exploitation of an infant or child by a parent or caretaker.

Georgia State law requires that medical and child service organization personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

902 PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE FEEDING

DECISIONS AND/OR PREPARE FOOD

IV

Infant whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

x mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
x physical disability which restricts or limits food preparation abilities x current use of or history of abusing alcohol or other drugs

Document: The caregivers limited abilities in the participant's health record.

904 ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-164

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

502

TRANSFER OF CERTIFICATION

I, II, IV

Person with a current valid Verification of Certification (VOC) card from another state or local agency. The VOC card is valid until the certification period expires, and shall be accepted as proof of eligibility for program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion would be used primarily when the VOC card/document does not reflect another (more specific) nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving State agency.

401 OTHER DIETARY RISK

IV

RISK OF INAPPROPRIATE COMPLEMENTARY FEEDING PRACTICES > 4 MONTHS. (4 months through <12 months)

An infant 4 months of age who has begun to or is expected to begin to do any of the following practices is considered to be at risk of inappropriate complementary feeding:

1) consume complementary foods and beverages, or 2) eat independently, or 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans.

(This risk factor may be assigned only when an infant > 4 months of age does not qualify for risk 400 or for any other risk factor.)

CT-165

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
CHILDREN

Data Length or Height Weight Hemoglobin or Hematocrit Weight/Age Plotted Length or Height/Age Plotted Weight/Length or BMI for Age Plotted Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Documentation Required Required Required Required Required Required Required Required

CT-166

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA CHILDREN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2)

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

III

12-23 months of age: Hemoglobin: 10.9 gm or lower Hematocrit: 32.8% or lower

24 months-5 years of age: Hemoglobin: 11.0 gm or lower Hematocrit: 32.9% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-2)

103

UNDERWEIGHT

III

Less than or equal to the 10th percentile weight for length or Body Mass Index (BMI) for age based on Centers for Disease Control and Prevention (CDC) age/sex specific growth charts.

High Risk: Weight for length or BMI for age <5th percentile

113

OVERWEIGHT

III

Greater than or equal to 24 months old and BMI for age greater than or equal to the 95th percentile based on CDC age/sex specific growth charts. Can only be used if
standing height is taken.

High Risk: BMI for age >95th percentile

114

AT RISK OF BECOMING OVERWEIGHT

III

Greater than or equal to 24 months old and BMI for age greater than or equal to the 85th percentile and less than the 95th percentile based on the CDC age/sex specific
growth charts. Can only be used if standing height is taken.

121

SHORT STATURE

III

Less than or equal to the 10th percentile length or height for age based on CDC age/sex

specific growth charts. (if < 24 months of age and < 38 weeks gestation use adjusted

age)

High Risk: Length or height for age <5th percentile

CT-167

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

134

FAILURE TO THRIVE

Presence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician.

Document: Diagnosis in participant's health record. High Risk: Diagnosed failure to thrive

PRIORITY III

135

INADEQUATE GROWTH

III

A low rate of weight gain over a six-month period as defined by the following chart:

Age in Months at Certification
12 months >12 - 60 months

Weight Gain in previous 6-month interval*
< 3 pounds < 1 pound

*Note: Use only for an interval of 6 months +/- 2 weeks.

High Risk: Inadequate growth

141

LOW BIRTH WEIGHT (children < 24 months of age)

III

Birth weight < 5 lbs 8 oz (< 2500 g)

Document: Birth weight of participant in health record.

142

PREMATURITY (Children < 24 months of age)

Born at 37 weeks gestation or less

III

Document: Weeks gestation in participant's health record.

211

ELEVATED BLOOD LEAD LEVELS

III

Blood lead level of >10 Pg/deciliter

Document: Date of blood test and blood lead level in participant's health record. Must be within the past 6 months.
High Risk: Blood lead level of >10 Pg/deciliter

CT-168

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

PRIORITY III

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micronutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

Presence of nutrient deficiency diseases diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition participant's health record.

High Risk: Diagnosed nutrient deficiency disease

342

GASTRO-INTESTINAL DISORDERS

III

Diseases or conditions that interfere with the intake or absorption of nutrients. The conditions include, but are not limited to: stomach or intestinal ulcers, liver disease, bowel enterocolitis and syndrome, pancreatitis, malabsorption syndromes, gallbladder disease, inflammatory bowel disease (including ulcerative colitis and crohn's disease)

Presence of gastro-intestinal disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

CT-169

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

343

DIABETES MELLITUS

III

Presence of diabetes mellitus diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition, and current diet prescription (if provided) in participant's health record.

High Risk: Diagnosed diabetes mellitus

344

THYROID DISORDERS

III Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

III Presence of hypertension diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypertension

CT-170

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

346

RENAL DISEASE

Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition participant's health record.

High Risk: Diagnosed renal disease

PRIORITY III

347

CANCER

III

The current condition, or the treatment for the condition MUST be severe enough to affect nutritional status. Presence of cancer diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

III

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebal palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

CT-171

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

III

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting
under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed genetic and congenital disorder

351

INBORN ERRORS OF METABOLISM

III

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed inborn error of metabolism

CT-172

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

352

INFECTIOUS DISEASES

III

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or
health professional acting under standing orders of a physician.

Document: Diagnosis, and approximate dates of each occurrence, and name of the physician that is treating this condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above.

353

FOOD ALLERGIES

III

Presence of food allergy diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed food allergy

CT-173

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PRIORITY

354

CELIAC DISEASE

III

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac disease diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

III Presence of lactose intolerance diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician; OR symptoms described by caregiver must be well documented by the competent professional authority

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record; OR list of symptoms described by caregiver/participant (i.e., nausea, cramps, abdominal bloating, and/or diarrhea). With list of symptoms, indicate that ingestion of dairy products causes these and avoidance of such products eliminates them.

High Risk: Lactose intolerance

356

HYPOGLYCEMIA

III

Presence of hypoglycemia diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypoglycemia

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CODE

357

DRUG/NUTRIENT INTERACTIONS

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug and medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

PRIORITY III

359

RECENT MAJOR SURGERY, TRAUMA, BURNS

III

Major surgery, trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported by caregiver. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns within the past 2 months.

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CODE

PRIORITY

360

OTHER MEDICAL CONDITIONS

III

Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate persistent or severe asthma.

Presence of other medical conditions diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status.

361

DEPRESSION

III

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

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CODE

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Presence of developmental, sensory or motor delay diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Specific condition/description of the delay and how it interferes with the ability to eat, and the name of the physician that is treating this condition in the participant's health record.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

PRIORITY III

381

DENTAL PROBLEMS

III

Diagnosis of dental problems by a physician or health professional working under standing orders of a physician or adequate documentation by the competent professional authority. Including but not limited to:

x Presence of nursing bottle caries x Smooth surface decay of the maxillary anterior and the primary molars

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

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CODE

PRIORITY

382

FETAL ALCOHOL SYNDROME

III

Fetal Alcohol Syndrome (FAS) is based on the presence of retarded growth, a pattern of facial abnormalities and abnormalities of the central nervous system, including mental retardation. Presence of FAS diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed fetal alcohol syndrome

400

INAPPROPRIATE NUTRITION PRACTICES

V

Routine nutrition practices that may result in impaired nutrient status, disease, or
health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

801

HOMELESSNESS

V Homelessness as defined in the Special Population Section of the Georgia WIC Procedures Manual.

802

MIGRANCY

V

Migrancy as defined in the Special Population Section of the Georgia WIC Procedures Manual.

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CODE

PRIORITY

901

RECIPIENT OF ABUSE

V Child abuse/neglect within past 6 months as self-reported by the caregiver, or as documented by a social worker, health care provider or on other appropriate documents, or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Child abuse/neglect refers to any recent act, or failure to act, resulting in:

x

Imminent risk or serious harm

x

Serious physical or emotional harm

x

Sexual abuse or exploitation of an infant or child by a parent or caretaker.

Georgia State law requires that medical and child service organization personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

902

PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE FEEDING

V

DECISIONS AND/OR PREPARE FOOD

Child whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

x mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
x physical disability which restricts or limits food preparation abilities x current use of or history of abusing alcohol or other drugs

Document: The caregiver's limited abilities in the participant's health record.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

III

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

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CODE 502

PRIORITY

TRANSFER OF CERTIFICATION
Person with a current valid Verification of Certification (VOC) card from another state or local agency. The VOC card is valid until the certification period expires, and shall be accepted as proof of eligibility for program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants
This criterion would be used primarily when the VOC card/document does not reflect another (more specific) nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving State agency.

III, V

401 OTHER DIETARY RISK

V

RISK OF INAPPROPRIATE COMPLEMENTARY FEEDING PRACTICES < 24 MONTHS OF AGE (12 months through <24 months)

A child who has begun to or is expected to begin to do any of the following practices is considered to be at risk of inappropriate complementary feeding:

1) consume complementary foods and beverages, or 2) eat independently, or 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans.

OR

FAILURE TO MEET DIETARY GUIDELINES > 24 MONTHS OF AGE

A child who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a child does not qualify for risk 400 or for any other risk factor.)

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APPENDICES

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TABLE OF APPENDICES

APPENDICES REFERENCED IN RISK CRITERIA SECTION

Appendix

A-1

WIC Maternal High Risk Criteria..................................................

Page 92

A-2

WIC High Risk Criteria for Infants and Children..............................

93

B-1

Women's Health Recommended Guidelines for Iron Supplementation, Based on Treatment Values...............................

94

B-2

Child Health Recommended Guidelines for Iron Supplementation,

Based on Treatment Values.......................................................

95

C-1

Body Mass Index (BMI) Table for Determining Weight

Classification for Pregnant Women............................................

96

C-2

Body Mass Index (BMI) Table for Determining Weight Classification for Postpartum Women...........................................................

97

C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age...........

98

D

Physical Signs Suggestive of Nutrient Deficiencies........................

99

E-1

Alcohol and Cigarettes...............................................................

101

E-2

Common Names of Illegal (Street) Drugs/Drugs of

Abuse....................................................................................

102

F

Recommended Food Intake Patterns..........................................

103

G

Inappropriate Nutrition Practices................................................

104

H

Products Containing Caffeine......................................................

109

I

Clear Liquids...........................................................................

111

J

Instructions for Use of the Prenatal Weight Gain Grid.....................

112

K-1

Measuring Length.....................................................................

113

K-2

Measuring Weight ("Infant" Scale)................................................

114

K-3

Measuring Height......................................................................

115

K-4

Measuring Weight (Standing)......................................................

116

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Appendix

L

Instructions for Use of the Growth Charts.....................................

M

Use and Interpretation of the Growth Charts..................................

Page 117 121

APPENDICES PROVIDED FOR SUPPLEMENTAL INFORMATION

N

Food Sources of Vitamin A......................................................... 122

O

Food Sources of Vitamin C.........................................................

123

P

Food Sources of Folate.............................................................

124

Q

Food Sources of Iron................................................................. 125

R

Food Source of Calcium............................................................ 126

S

Herbs: Their Use and Potential Risks...........................................

127

T

Key for Entering Weeks Breastfed...............................................

128

U

Infant Formula Preparation......................................................... 129

V-1

Conversion Tables and Equivalents.............................................

132

V-2

Approximate Metric and Imperial Equivalents.................................

133

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WIC MATERNAL HIGH RISK CRITERIA

Appendix A-1

Any WIC prenatal, breastfeeding, or non-breastfeeding woman who has the following high risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria Hemoglobin or hematocrit at treatment level

Risk Code 201

Appendix B-1

Underweight Prenatal Women: Body Mass Index <19.8 Postpartum Women: Body Mass Index <18.5
Overweight (Only High Risk if Obese) Prenatal Women: Body Mass Index >29.0 Postpartum Women: Body Mass Index > 29.9

C-1; C-2

101

Body Mass Index

Tables

C-1; C-2

111

Body Mass Index Tables

Low maternal weight gain

131

Weight loss during pregnancy

132

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or health professional acting under standing orders of a physician
EDC or delivery prior to 17th birthday

341-349; 351-360;
362
331

Blood lead level > 10 Pg/dl

211

Breastfeeding complications; referral to appropriate BF counselor must be made

602

Hyperemesis Gravidarum

301

Gestational diabetes

302

Multifetal gestation

335

Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

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Appendix A-2
WIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN
WIC infants and children who have the following high risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria Hemoglobin or hematocrit at treatment level Underweight (weight for length or Body Mass Index for age <5th %) Overweight (Body Mass Index for age >95th %) Short stature (length/height for age <5th %)

Risk Code 201 103 113 121

Appendix B-2

Failure to thrive

134

Inadequate growth

135

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet or special prescribed formula as ordered by a physician or health professional acting under standing orders of a physician

341-357; 359; 360; 362; 382

Low birthweight infant (infant weighing 2500 grams [5 pounds] or less

at birth). May only be used for infants as high risk criteria.

141

Blood lead level > 10Pg/dl

211

Breastfeeding complications; infants only; referral to appropriate BF

counselor must be made

603

Fetal Alcohol Syndrome (child only)

382

Any condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required

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Appendix B-1
WOMEN'S HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION
BASED ON TREATMENT VALUES

Hemoglobin

Hematocrit

Treatment Value

Treatment Value

Non-Smokers Smokers Non-Smokers Smokers

Prenatal Woman 1st Trimester 2nd Trimester

10.9 gm or lower

11.2 gm or lower

32.9% or lower

33.9% or lower

Prenatal Woman 2nd Trimester

10.4 gm or lower

10.7 gm or lower

31.9% or lower

32.9% or lower

Non-Pregnant and/or Lactating Woman (<15 years of age)

11.7 gm or lower

12.0 gm or lower

35.8% or lower

36.8% or lower

Non-Pregnant and/or Lactating Woman (>15 years of age)

11.9 gm or lower

12.2 gm or lower

35.8% or lower

36.8% or lower

For Prenatal Women:
Begin routine supplementation of a prenatal vitamin and mineral supplement to include 27-30 mg/day of elemental iron for all pregnant women at the 1st prenatal visit. For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with
a therapeutic dose of 60-120 mg of elemental iron/day.

NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multi-vitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day. When the hemoglobin/hematocrit reaches the acceptable value for the specific stage pregnancy, decrease iron dosage to 30 mg/day

PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% Hemoglobin more than 15.0 g/dL or hematocrit more than 45.0% (2nd and 3rd trimester) If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron
supplementation regimen and the absence of acute illness

For Non-Pregnant/Lactating Women: For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60-120 mg of elemental iron/day.

NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multivitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day. PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron
supplementation regimen and the absence of acute illness

After 4 weeks, if the hemoglobin increases > 1g/dl or if the hematocrit increases > 3 %, continue treatment for 2-3 more months.

Reference: CDC/MMWR: April 3, 1998. Recommendations to Prevent and Control Iron Deficiency in the United States

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Appendix B-2
CHILD HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION BASED ON TREATMENT VALUES

Hemoglobin Treatment
Value

Hematocrit Treatment
Value

Treatment Regimen

Infant 6 through 11 months

10.9 gm or lower

32.8% or lower

Dosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID

Child 12 through 23 months

10.9 gm or lower

32.8% or lower

Dosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID

Child 2 through 5 years

11.0 gm or lower

32.9% or lower

Dosage: 1.2 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 30mg BID

x Premature and low birth weight infants, infants of multiple births, and infants with suspected blood losses should be screened before 6 months of age, preferably at 6-8 weeks postnatal.
x Routine screening for iron deficiency anemia is not recommended in the first 6 months of life.
x Treatment of iron deficiency anemia is 3 mg per kilogram per day. x Refer to the package insert of iron preparation to correctly calculate the appropriate dosage
of elemental iron. Most pediatric chewable preparations (i.e., Feostat, 100 mg) contain 33 mg elemental iron per tablet as ferrous fumarate. Non-chewable preparations for older patients (i.e., Feosol, 300 mg) contain 60-65 mg per tablet or capsule elemental iron as ferrous sulfate.

Sources: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, April 3, 1998/Vol.47/No. RR-3.
Nutrition Guidelines for Practice: A Manual for Providing Quality Nutrition Services. Nutrition Section, 1997.

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Appendix C-1
Body Mass Index (BMI) Table for Determining Weight Classification for Pregnant Women 1

Height (Inches)

Underweight BMI <19.8

Normal Weight BMI 19.8-26.0

Overweight BMI 26.1-29.0

Obese BMI >29.0

58"

<95

95-124

125-138

>138

59"

<98

98-128

129-143

>143

60"

<102

102-133

134-148

>148

61"

<105

105-137

138-153

>153

62"

<108

108-142

143-158

>158

63"

<112

112-146

147-163

>163

64"

<116

116-151

152-169

>169

65"

<119

119-156

157-174

>174

66"

<123

123-161

162-179

>179

67"

<127

127-166

167-185

>185

68"

<130

130-171

172-190

>190

69"

<134

134-176

177-196

>196

70"

<138

138-181

182-202

>202

71"

<142

142-186

187-208

>208

72"

<146

146-191

192-213

>213

1Adapted from the Institute of Medicine: Nutrition During Pregnancy. National Academy Press,1990.

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Appendix C-2
Body Mass Index (BMI) Table for Determining Weight Classification for Postpartum Women 1

Height (Inches)

Underweight BMI <18.5

Normal Weight BMI 18.5-24.9

Overweight BMI 25.0-29.9

Obese BMI >29.9

58"

<89

89-118

119-142

>142

59"

<92

92-123

124-147

>147

60"

<95

95-127

128-152

>152

61"

<98

98-131

132-157

>157

62"

<101

101-135

136-163

>163

63"

<105

105-140

141-168

>168

64"

<108

108-144

145-173

>173

65"

<111

111-149

150-179

>179

66"

<115

115-154

155-185

>185

67"

<118

118-158

159-190

>190

68"

<122

122-163

164-196

>196

69"

<125

125-168

169-202

>202

70"

<129

129-173

174-208

>208

71"

<133

133-178

179-214

>214

72"

<137

137-183

184-220

>220

1Adapted from Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). NIH Publication No. 98-4083.

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Appendix C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age

Inadequate growth for infants between 1 and 6 months of age is based on two weight measurements taken at least 1 month (4.3 weeks) apart, using the following guidelines:

Age
1 month 1-2 months 2-3 months 3-4 months 4-5 months 5-6 months

Minimum Acceptable Weight Gain
19 oz 27 oz/month (6 oz/wk) 19 oz/month (4 oz/wk) 17 oz/month (4 oz/wk) 15 oz/month (3 oz/wk) 13 oz/month (3 oz/wk)

Example:

Date of Measurement 09/13/98 (birth) 10/26/98 (6 weeks, 1 day old)

Weight 7 lbs 6 oz 9 lbs 3 oz

1. Calculate infant's age:

98 - 98

10 26 09 13 01 mo 13 days = 1 month + 1 week + 6 days = about 1 mo + 2 wks

2. Calculate minimum acceptable weight gain:
1st month minimum acceptable weight = 19 oz 1-2 months minimum acceptable weight/wk = 6 oz (2x 6 = 12 oz) Total acceptable weight = 19 oz + 12 oz = 31 oz = 1 lb 15 oz

3. Compare actual weight gain (1 lb 13 oz) to acceptable minimum (1 lb 15 oz). This infant's weight gain is below acceptable minimum, so you can apply the criterion for inadequate growth.

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Appendix D PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area Normal Appearance

Hair

shiny; firm; not easily

plucked

Eyes

bright; clear; shiny; no sores

at corners of eyelids;

membranes healthy pink and moist; no prominent blood vessels

Signs Suggestive of Nutrient Deficiency(ies)
lack of natural shine; dull; thin; loss of curl; color changes (flag sign); easily plucked
eye membranes pale;
Bitot's spots; red membranes; dryness of membranes; dull appearance of cornea (cornea xerosis); softening of cornea (keratomalacia);
redness and fissuring of eyelid corners

Lips

smooth; not chapped or

redness or swelling of mouth or lips (cheilosis);

swollen

bilateral cracks, white or pink lesions at corners of

mouth (angular stomatitis) and/or scars

Gums Tongue

healthy, red; do not bleed; not spongy; bleeding; receding swollen

deep red; not swollen or smooth

scarlet; raw; edematous (glossitis)

purplish color (magenta); smooth; pale; slick; atrophied taste buds (papillae)

Face and Neck

skin color uniform, smooth, pink; healthy appearing; not swollen

diffuse depigmentation; darkening of skin over cheeks and under eyes;

scaling of skin around nostrils (nasolabial seborrhea) swollen (moon) face; front of neck swollen (thyroid enlargement);

swollen cheeks (bilateral parotid enlargement)

Nutrient Consideration(s) inadequate protein and calories
anemia (inadequate iron, folacin, or vitamin B-12) inadequate Vitamin A
inadequate riboflavin, Vitamin B-6, and niacin inadequate niacin and riboflavin inadequate riboflavin, niacin, iron and Vitamin B-6 inadequate ascorbic acid
inadequate niacin, riboflavin, folacin, iron, Vitamins B-6 and B-12 inadequate riboflavin inadequate folacin, Vitamin B-12, iron and niacin inadequate protein inadequate calories and niacin inadequate riboflavin, niacin, and Vitamin B-6 inadequate protein inadequate protein; inadequate iodine inadequate protein

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Appendix D (cont.) PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area Normal Appearance

Skin

no signs of swelling rashes,

dark or light spots

Teeth

no cavities, no pain, bright

Head / Neck
Nails

face not swollen firm, pink

Muscular and Skeletal Systems

good muscle tone; some fat under skin; can walk or run without pain

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

dry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis);

Inadequate Vitamin A or Essential fatty acids

pinhead-size purplish skin hemorrhages (petechiae);

Inadequate Vitamin C

excessive bruising;

Inadequate Vitamin K

red, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis);

Inadequate niacin and Tryptophan

extensive lightness and darkness of skin (flaky, pressure sores(decubiti)

Inadequate protein, Vitamin C, and zinc

may be some missing or erupting abnormally; gray or black spots (fluorosis); cavities (caries) [signs are to be severe enough to interfere with mastication and/or other health implications]*

Inadequate Vitamin D and Vitamin A

thyroid enlargement (front of neck); parotid enlargement (cheeks become swollen)

Inadequate iodine; inadequate protein

nails are spoon-shaped (koilonychia); brittle ridged nails, pale nail beds

Inadequate iron; Vitamin A toxicity

muscles have "wasted" appearance; baby's skull bones are thin and soft (craniotabes); round swelling of front and side of head (frontal and parietal bossing); swelling of ends of bones (epiphyseal enlargement); small bumps on both sides of chest wall (on ribs); beading of ribs; baby's soft spot on head does not harden at proper time (persistently open anterior fontanelle); knock-knees or bow-legs; bleeding into muscle (musculoskeletal hemorrhages); person cannot get up or walk properly

Inadequate protein Inadequate thiamin Inadequate Vitamin D

Sources: 1. American Journal of Public Health, Supplement, November 1973, p. 19. 2. Georgia Dietetic Association Diet Manual, 1992.

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ALCOHOL AND CIGARETTES

Appendix E-1

Alcohol Equivalents:

One serving of alcohol =

12 ounces of beer (light or regular);

12 ounces of wine cooler;

5 ounces of wine (light or regular);

1 1/2 ounces of liquor.

Key for Entering Ounces of Alcohol/Week: On the WIC Assessment/Certification Form enter the amount of alcohol in ounces per week using the above equivalent chart.

Key: 00 ounces/week = no alcohol intake

01 ounces/week = greater than 0 and up to 1 1/2 ounce/week

02-98 ounces week = amount of intake

99 ounces/week = greater than 98 ounces/week

Binge drinking: drinks 5 or more (>5) drinks on the same occasion on at least one day in the past 30 days.

Heavy drinking: drinks 5 or more (>5) drinks on the same occasion on five or more days in the previous 30 days.

Key for Entering Number of Cigarettes/Cigars/Pipes Smoked: On the WIC Assessment/Certification Form record the average number of cigarettes/cigars/pipes smoked per day. If the client reports smoking on average less than once per day, record the average number of cigarettes/cigars/pipes smoked per week. If the client reports smoking on average less than once per week, record the average number of cigarettes/cigars/pipes smoked per month.

Key: 01-98/day = average number of cigarettes/cigars/pipes smoked per day

99/day = greater than 98 cigarettes/cigars/pipes smoked per day

01-06/week = average number of cigarettes/cigars/pipes smoked per week

01-03/month = average number of cigarettes/cigars/pipes smoked per month

Note: The usual number of cigarettes in a pack is equal to 20. This number may vary.

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COMMON NAMES FOR ILLEGAL (STREET) DRUGS/DRUGS OF ABUSE

Controlled Substances Cannabis: Marijuana
Tetrahydrocannabinol Hashish, Hashish Oil

Common Names
Acapulco Gold, Grass, Pot, Reefer, Sinsemilla, Thai Sticks
Marinol, THC Hash, Hash Oil

Hallucinogens: LSD (lysergic acid diethylamide) Mescaline, Peyote Amphetamine Variants
Phencyclidine and Analogs

Acid, Microdot
Buttons, Cactus, Mescal
2,5-DMA, DOB, DOM, Ecstasy, MDA, MDMA, STP
Angel Dust, Hog, Loveboat, PCE, PCP, PCPy, TCP

Narcotics: Heroin

Diacetylmorphine, Horse, Smack

Stimulants:

Cocaine

Coke, Crack, Flake, Snow, Rock

Source: Drugs of Abuse. Drug Enforcement Administration and The National Guard. Arlington, VA, 1997.

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RECOMMENDED FOOD INTAKE PATTERNS

Appendix F

Food Group

Birth to 5/6 Months

Milk, Yogurt & Cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group

Breast milk, every 2-3 hrs or Iron fortified formula, 2.5 oz/lb (18-35 ozs)
None

5/6 Months to 12 months
Breast milk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs)
Add after 6 months and before 9 months

1 Year 2 cups1
2 ounces

2-3 Years 2 cups
2 ounces

4-6 Years 2 cups
3-4 ounces

Pregnant Teen/ Pregnant Adult
3 cups

Breastfeeding Teen/ Breastfeeding Adult
3 cups

Teen Postpartum/ Adult Postpartum
3 cups

6- 6 ounces

6 ounces

5- 5 ounces

Fruit Group

None

Vegetable Group

None

Add after 6 months and before 9 months
Add after 6 months and before 9 months

1 cup2 1 cup

1 cup2 1 cup

1- 1 cups

2 cups

1 cups

3 cups

2-2 cups 3-3 cups

1 -2 cups 2 cups

Grain Group

None

Add iron Fortified cereal at 6 months

3 oz equivalents

3 oz equivalents

4- 5 oz equivalents

7- 8 oz equivalents 7- 8 oz equivalents 6 oz equivalents

Discretionary Calorie Allowance3

None

None

165

165

171

290- 362

362- 410

195-267

1 AAP recommends whole milk for children until 2 years old 2 AAP recommends no more than 6 ounces of juice per day for children 3 Discretionary Calorie Allowance is the remaining amount of calories in a food intake pattern after accounting for the calories needed

for all food groups- preferably using forms of foods that are fat-free or low-fat and with no added sugars.

Milk, Yogurt & Cheese Group: Most milk group choices should be fat-free or low-fat for those over the age of 2 years. 1 cup equivalent from this group =
1 cup milk/yogurt 1 ounces natural cheese (i.e. cheddar, Colby, longhorn) 2 ounces processed cheese (i.e. American, Swiss) 2 cups cottage cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group: 1 ounce equivalent from this group=
1 ounce lean meat, poultry or fish 1 egg ounce nuts or seeds cup cooked dry beans or tofu 1 tablespoon peanut butter

Fruit Group: 1 cup equivalent from this group=
1 medium fruit 1 cup freshly cut canned or frozen fruit cup dried fruit 1 cup 100% fruit juice
Vegetable Group: 1 serving =
1 cup cooked or chopped 2 cups raw leafy salad greens 1 cup 100% vegetable juice
Grain Group: At least half of all grains consumed should be whole grains 1ounce equivalent from this group =

1 slice of Bread , Hamburger Bun, 1 small muffin cup cooked cereal, rice or pasta 1 cup ready to eat cereal flakes All information provided courtesy of MyPyramid.gov For more information http://download.journals.elsevierhealth.com/pdfs/journals/1499-4046/PIIS1499404606005628.pdf

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Inappropriate Nutrition Practices for Women

Appendix G

Inappropriate Nutrition Practices for Women

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Potentially Harmful Dietary Supplements
Consuming Dietary Supplements with potentially harmful consequences. Restrictive Diet
Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake or absorption of essential nutrients following bariatric surgery. Routine ingestion of non-food items (pica)
Compulsively ingesting non-food items (pica).
Inadequate vitamin/mineral supplementation recognized as essential by national public health policy.
Pregnant Women Potentially unsafe food consumption
Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms.

Examples of Dietary supplements which when ingested in excess of recommended dosages, may be toxic or have harmful consequences:
x Single or multiple vitamins x Mineral supplements; and x Herbal or botanical supplements/remedies/teas. x Strict vegan diet; x Low-carbohydrate, high-protein diet; x Macrobiotic diet; and x Any other diet restricting calories and/or essential nutrients.

Non-food items:

x Ashes;

x Clay;

x Baking soda;

x Dust;

x Burnt matches;

x Large quantities of ice

x Carpet fibers;

x Paint chips;

x Chalk;

x Soil; and

x Cigarettes;

x Starch (laundry and cornstarch)

x Consumption of less than 30 mg of iron as a supplement daily by

pregnant woman.

x Consumption of less than 400 mcg of folic acid from fortified foods

and/or supplements daily by non-pregnant women

Potentially harmful foods: x Raw fish or shellfish, including oysters, clams, mussels, and scallops; x Refrigerated smoked seafood, unless it is an ingredient in a cooked dish, such as a casserole; x Raw or undercooked meat or poultry; x Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot; x Refrigerated pt or meat spreads; x Unpasteurized milk or foods containing unpasteurized milk; x Soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk"; x Raw or undercooked eggs or foods containing raw or lightly cooked eggs including certain salad dressings, cookie and cake batters, sauces, and beverages such as unpasteurized eggnog; x Raw sprouts (alfalfa, clover, and radish); or x Unpasteurized fruit or vegetable juices.

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Appendix G (cont.) Inappropriate Nutrition Practices for Children

Inappropriate Nutrition Practices for Examples of Inappropriate Nutrition Practices

Children

(Including but not limited to)

Routinely feeding inappropriate beverages as the primary milk source.

Examples of inappropriate beverages as primary milk source:
x Non-fat or reduced-fat milks (between 12 and 24 months of age only) or sweetened condensed milk; and
x Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other "homemade concoctions."

Routinely feeding a child any sugarcontaining fluids.
Routinely using nursing bottle, cups, or pacifiers improperly.

Examples of sugar-containing fluids:

x Soda/soft drinks;

x Corn syrup solutions; and

x Gelatin water;

x Sweetened tea.

x Using a bottle to feed:

Fruit juice, or

Diluted cereal or other solid foods.

x Allowing the child to fall asleep or be put to bed with a

bottle at naps or bedtime.

x Allowing the child to use the bottle without restriction (e.g.,

walking around with a bottle) or as a pacifier.

x Using a bottle for feeding or drinking beyond 14 months of

age.

x Using a pacifier dipped in sweet agents such as sugar,

honey, or syrups.

x Allowing a child to carry around and drink, throughout the

day, from covered or training cups.

Routinely using feeding practices that disregard the developmental needs or stages of the child.

x Inability to recognize, insensitivity to, or disregarding the child's cues for hunger and satiety (e.g., forcing a child to eat a certain type and/or amount of food or beverage or ignoring a hungry child's request for appropriate foods).
x Not supporting a child's need for growing independence with self-feeding (e.g.; solely spoon-feeding a child who is able and ready to finger-feed and/or try self-feeding with appropriate utensils).
x Feeding a child with an inappropriate texture based on his/her developmental stage (e.g., feeding primarily purees or liquid food when the child is read and capable of eating mashed, chopped, or appropriate finger food).

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Appendix G (cont.)

Potentially unsafe food consumption.
Feeding foods to a child that could be contaminated with harmful microorganisms.

Examples of potentially harmful foods for a child: x Unpasteurized fruit or vegetable juices. x Unpasteurized dairy products or soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk x Raw or undercooked meat, fish, poultry, or eggs x Raw sprouts (alfalfa, clover, and radish) x Undercooked or raw tofu; and x Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot;

Routinely feeding a diet very low in calories and/or essential nutrients.

Examples: x Vegan Diet; x Macrobiotic diet; and x Other diets very low in calories and/or essential nutrients.

Feeding dietary supplements with potentially harmful consequences

Examples of dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences:
x Single or multiple vitamins x Mineral supplements; and x Herbal or botanical supplements/remedies/teas

Routinely not providing dietary supplements as recognized as essential by national public health policy when a child's diet alone cannot meet nutrient requirements.

x Providing children under 36 months of age less than 0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride.
x Providing children 36-60 months of age less than 0.50 mg of fluoride daily when the water contains less than 0.3 ppm fluoride.

Routine ingestion of non-food items (pica)

x Ashes; x Carpet fibers; x Cigarettes or cigarette butts; x Clay; x Dust; x Paint chips; x Soil; and x Starch (laundry and cornstarch)

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Appendix G (cont'd) Inappropriate Nutrition Practices for Infants

Inappropriate Nutrition Practices for Infants

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Breast-milk or Formula Substitute Routinely substitute(s) for breast milk or FDA approved iron-fortified formula as the primary source during the first year of life.
Inappropriate use of bottles or SugarContaining Fluids.
Inappropriate Introduction of Solid Foods Routinely offering complementary foods* or other substances that are inappropriate in type or timing. Feeding Practices not Developmentally Appropriate Routinely using feeding practices that disregard the developmental needs or stages of the child.

Examples of substitutes: x Low iron formula without iron supplementation; x Cow's milk, goat milk, or sheep milk (whole, reduced-fat low-fat, skim) canned evaporated sweetened condensed milk; and x Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other "homemade concoctions." x Using a bottle to feed fruit juice x Adding any food (cereal or other solid foods) to the infant's bottle. x Feeding any sugar-containing fluids such as, soda/soft drinks; gelatin water; corn syrup solutions; and sweetened tea. x Allowing the child to fall asleep or be put to bed with a bottle at naps or bedtime. x Allowing the child to use the bottle without restriction (e.g., walking around with a bottle) or as a pacifier. x Propping the bottle when feeding. x Allowing a child to carry around and drink, throughout the day, from covered or training cups.
x Adding sweet agents such as sugar, honey, or syrups to any beverage (including water) or prepared food, or used on a pacifier; or
x Introduction of any food other than breast milk or iron-fortified infant formula before 4 months of age.
*Complementary foods are any foods or beverages other than breast milk or infant formula. x Inability to recognize, insensitivity to, or disregarding the child's cues for hunger and satiety (e.g., forcing an infant to eat a certain type and/or amount of food or beverage or ignoring a hungry infant's hunger cues). x Feeding foods of inappropriate consistency, size, or shape that put infants at risk of choking. x Not supporting an infant's need for growing independence with selffeeding (e.g.; solely spoon-feeding an infant who is able and ready to finger-feed and/or try self-feeding with appropriate utensils). x Feeding an infant with an inappropriate texture based on his/her developmental stage (e.g., feeding primarily purees or liquid food when the child is read and capable of eating mashed, chopped, or appropriate finger food).

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Appendix G (cont.)

Potentially unsafe food consumption
Feeding foods to a child that could be contaminated with harmful microorganisms.
Inappropriate Formula Preparation. Routinely feeding inappropriately diluted formula Restrictive Nursing. Routinely limiting the frequency of nursing of the exclusively breastfeed infant when breast milk is the sole source of nutrients. Restrictive Diet
Routinely feeding a diet very low in calories and/or essential nutrients Lack of proper Sanitation. Routinely using inappropriate sanitation in preparation, handling, and storage of expressed breast milk or formula.
Potentially Harmful Dietary Supplements. Feeding dietary supplements with potentially harmful consequences Lack of Essential Dietary Supplements.
Routinely not providing dietary supplements as recognized as essential by national public health policy when an Infant's diet alone cannot meet nutrient requirements.

Examples of potentially harmful foods for a child: x Unpasteurized fruit or vegetable juices. x Unpasteurized dairy products or soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk x Honey (added to liquids or solid food, used in cooking, as part of processed foods, on pacifier, etc.); x Raw or undercooked meat, fish, poultry, or eggs x Raw sprouts (alfalfa, clover, and radish) x Undercooked or raw tofu; and x Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot; x Failure to follow manufacturer's dilution instructions (to include stretching formula for household economic reasons). x Failure to follow specific instructions accompanying a prescription.

Examples of inappropriate frequency of nursing: x Scheduled feedings instead of demand feedings; x Less than8 feedings in a 24 hours if less than 2 months of age; and x Less than 6 feedings in 24 hours if between 2 and 6 months of age.

Examples:

x Vegan Diet; x Macrobiotic diet; and x Other diets very low in calories and/or essential nutrients

Examples of inappropriate sanitation: x Limited or no access to a: Safe water supply (documented by appropriate officials) Heat source for sterilization, and/or; Refrigerator or freezer storage. x Failure to properly prepare, handle, and store bottles or storage containers of expressed breast milk or formula.
Examples of Dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences:
x Single or multiple vitamins x Mineral supplements; and x Herbal or botanical supplements/remedies/teas x Infants who are 6 months of age or older who are ingesting less than
0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride. x Breast-fed infants who are ingesting less than 500 mL (16.9oz) per day of vitamin-D fortified formula and are not taking a supplement of 200 IU of vitamin D. x Non-breastfed infants who are ingesting less than 500 mL (16.9oz) per day of vitamin-D fortified formula and are not taking a supplement of 200 IU of vitamin D.

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Attachment CT-6 (cont'd)

PRODUCTS CONTAINING CAFFEINE

Appendix H

PRODUCT

AVERAGE CAFFEINE CONTENT (mg)

CAFFEINE RANGE (mg)

Coffee (5-oz cup)

Brewed, drip

115

Brewed, percolator

80

Instant

65

Decaffeinated, brewed

3

Decaffeinated, instant

2

Tea

Brewed, major US brands (5-oz)

40

Brewed, imported brand (5-oz)

60

Instant (5-oz)

30

Iced (12-oz)

70

Chocolate Beverages

Cocoa beverage (5-oz)

4

Chocolate milk (8-oz)

5

Milk chocolate (1-oz)

6

Dark chocolate, semi-sweet

20

(1 oz)

Baker's chocolate (1 oz)

26

Chocolate-flavored syrup (1 oz)

4

60-180 40-170 30-120
2-5 1-5
20-90 25-110 25-50 67-76
2-20 2-7 1-15 5-35
26 4

PRODUCT
Soft Drinks (12-oz) Sugar-Free Mr. PIBB Mountain Dew Mello Yellow TAB Coca-Cola Diet Coke Mountain Dew Shasta Cola Shasta Diet Cola Mr. PIBB Dr. Pepper Pepsi Cola Diet Pepsi RC Cola Diet RC

CAFFEINE CONTENT (mg)
58.8 54.0 52.8 46.8 45.6 44.4 54.0 44.4 40.8 39.6 39.6 38.0 36.0 36.0 48.0

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Appendix H (cont'd) PRODUCTS CONTAINING CAFFEINE

PRODUCT

MILLIGRAMS CAFFEINE/DOSE

Diet Plan Non-Prescription Drugs

Caltrim Tablets

100

Caffeine-Free Dexatrim w/ Vitamin C

0

Dexatrim

200

X-tra Strength Dexatrim

200

Gold Medal

100

Odrinex

Pain Relievers Anacin and X-tra Strength Capron Capsules Tri Pain Caplets BC Tablet BC Powder Arthritis Strength BC Doan's Pills Duradyne Excedrin X-tra Strength Goody's Powder Goody's X-tra Strength Meadache Trigesic Vanquish Caplet Prolamine Capsules

32 32.4 16.2 16 32 36 32 15 65 32.5 16.25 32 30 33 140

Menstrual Relief

Aqua Ban

100

Midol

32.4

Midol Max Strength, Multi-Symptom

60

Sources: 1American Pharmaceutical Association and The National Professional Society of Pharmacists. (8th Ed.). (1986).
Handbook of Nonprescription Drugs.

2American Dietetic Association (ADA). (1992). Manual of Clinical Dietetics (4th ed.). Chicago, IL: Chicago Dietetic Association.

3Georgia Dietetic Association (GDA). (1992). Georgia Dietetic Association Diet Manual (4th ed.). Duluth, GA.

4Medical Economics Data Production Company. (15th Ed.). (1994). Physician's Desk Reference for Nonprescription Drugs, Montvale, N.J.

5U.S. Pharmacopeial Convention, Inc. (13th Ed.). (1993). Drug Information for the Health Care Professional USP DI.

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CLEAR LIQUIDS

Attachment CT-6 (cont'd) Appendix I

The following foods are considered clear liquids: All strained clear juices (apple, grape, cranberry) Carbonated beverages Clear broths Coffee Decaffeinated coffee Fruit ices Gelatin, plain Kool-Aid and other clear juice drinks Lemonade Popsicles Teas Water

Source:

Georgia Dietetic Association Diet Manual. Georgia Dietetic Association, Inc. Fourth edition, 1992.

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INSTRUCTIONS FOR USE OF THE PRENATAL WEIGHT GAIN GRID

Appendix J

1. Record applicant/participant's name.
2. Use Body Mass Index table (Appendix C-1) to determine if the applicant is Normal Weight, Underweight , Overweight , or Obese using pregravid weight. Select for use the prenatal weight gain grid that corresponds to the prenatal woman's pregravid weight status. If she is pregnant with twins, use the "Twins" grid regardless of her weight status.
3. Enter height in inches without shoes.
4. Use Weight History chart.
5. Enter pregravid weight as indicated. Enter date and weight at each visit.
6. Plot today's weight using the following steps:
a. Record the pregravid weight at the initial point of the selected weight curve, which is located on the left side of the grid at zero (0) point. From the chart or gestation calculator, determine the completed weeks of gestation.
b. Using the gain (or loss) in weight from the pregravid weight baseline and the completed gestational weeks (this visit) place an X on the point at which these two (2) lines meet.
c. If the patient does not know her pregravid weight, or if the weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated completed gestational week. Let this be a beginning point to plot future weights. Indicate that this weight is an estimate by writing "estimate" vertically on the grid next to the X. Use the "Normal" weight curve unless it is very obvious that the prenatal woman was overweight or underweight prior to gestation. Document this observation in the health record.
d. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid.

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Appendix K-1
MEASURING LENGTH Age:
Birth to 24 months
24-36 months, if proper position to measure stature cannot be achieved or with children less than 32 inches in stature.
Material/Equipment:
An accurate lengthboard for measuring infants is dedicated to length measurement. It has a firm, flat horizontal surface with a measuring tape in 1 mm (0.1 cm) or 1/8 inch increments, an immovable headpiece at a right angle to the tape, and a smoothly moveable footpiece, perpendicular to the tape.
Two (2) people required
Procedure:
1. Check to be sure that moveable foot piece slides easily and the headboard is at the zero (0) mark.
2. Remove headwear, shoes and bulky clothing. Instruct caretaker to apply gentle traction to ensure that the child's head is firmly against the headboard so that the eyes are pointing directly upward.
3. With the child positioned so that the shoulders, back and buttocks are flat along the center of the board, the measurer should hold the child's knees together, gently pushing them down against the board with one (1) hand to fully extend the child. With the other hand the measurer should slide the footboard to the child's feet until both heels touch the foot piece. Toes should be pointing directly upward.
4. Recheck head placement. Immediately remove the child's feet from contact with the footboard with one (1) hand, while holding the footboard securely in place with the other hand.
5. Measure length in inches to the nearest 1/8-inch. Repeat the measurement by sliding footboard away and starting again until two (2) readings agree within 1/4 inch.
6. Record the second reading promptly.

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Appendix K-2
MEASURING WEIGHT ("INFANT" SCALE)
Age:
Infants and very young children up to 35 pounds
Materials/Equipment:
Scales with beam balance and non-detachable weights or electronic, with a maximum weight of 40 lbs and weigh in ounce increments.
Scales must be calibrated yearly.
Procedure:
1. Check scales at zero (0) position. With weights in zero (0) position, indicator should point at zero (0). If not, use the adjustment screws to move adjustable zeroing weight until the beam is in zero (0) balance.
2. Remove shoes and clothes. Remove diaper if wet.
3. Place infant/child in center of scale (may be done sitting or lying down).
4. Move the weight on the main beam away from the zero (0) position (left to right) until the indicator shows excess weight, then move the weight back (right to left) towards the zero (0) position until too little weight has been obtained.
5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered and stationary. (Record weight)
6. Repeat the measurements by moving the fractional beam until two (2) readings agree within -ounce.
7. Record the second reading promptly.

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Appendix K-3
MEASURING HEIGHT
Age:
Children two (2) years of age and older who are at least 32 inches in stature
Adults
NOTE:Once measurements are started with child standing, all subsequent measurements must be done standing.
Material/Equipment:
An accurate stadiometer for stature measurements is designed for and dedicated to stature measurement. It can be wall mounted or portable. An appropriate stadiometer requires a vertical board with an attached metric rule and a horizontal headpiece (right angle headboard) that can be brought into contact with the most superior part of the head. The stadiometer should be able to read to 0.1 cm or 1/8 in.
Procedure:
1. Remove all bulky clothing, head and footwear.
2. Position the child/adult against the measuring device, instructing the child/adult to stand straight and tall.
3. Make sure the child/adult stands flat footed with feet slightly apart and knees extended; then check for three (3) contact points: (a) shoulders, (b) buttocks, and (c) the back of the heels.
4. Lower the moveable headboard until it firmly touches the crown of the head. The child/adult should be looking straight ahead, not upward or down at the floor.
5. Read the stature to the nearest 1/8-inch.
6. Repeat the adjustment of the headboard and re-measure until two (2) readings agree within 1/4 inch.
7. Record the second reading promptly.

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Appendix K-4
MEASURING WEIGHT (STANDING)
Age:
Adults, and children 2 years of age or older who can stand unattended by an adult
Materials/Equipment:
Standard electronic scale or platform beam scale with non-detachable weights that weighs in at least 1/4 pound or 100 gram increments.
Scales must be calibrated yearly
Procedure:
1. Check scales at zero (0) position. With weights in zero (0) position indicator should point at zero (0). If not, use adjustment screws to move the adjustable zeroing weight until the beam is in zero (0) balance.
2. Should be wearing minimal indoor clothing. Remove shoes, heavy clothing, belts, and heavy jewelry. Be sure pockets are empty.
3. Have child/adult stand in the center of the platform, arms hanging naturally. The child/adult must be free standing.
4. Move the weight on the main beam away from zero (0) until the indicator shows that excess weight has been added, then move the weight back towards the zero (0) position (right to left) until just barely too much weight has been removed.
5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered.
6. Make sure the child/adult is still not holding on, then record to the nearest 1/4 lb.
7. Have the child/adult step off scale and return weight to zero (0). Repeat until two (2) readings agree within 1/4 pound.
8. Record the second reading promptly.
Sources: Georgia Child and Adolescent Health Program Manual. DHR, Division of Public Health; 1987. A Guide to Pediatric Weighing and Measuring, DHHS; 1981.

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Appendix L

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

1. Select the appropriate chart for sex and age of the individual. When length measurements are taken with the individual lying down use the "Birth to 36 Months of Age" chart.

2. Record name and/or identifying number of the chart. Document birth date.

3. The child's age on the date on which measurements are taken must be determined before you start plotting the measurements. To figure out a child's age, follow this example:

Year

Month

Day

Date of Measurement

2002

4

21

Date of Birth

-1997

-8

-10

Child's Age

4 y

8

11

or 4 yrs 8 mos
As this example shows, you may have to borrow thirty (30) days from the month column and/or 12 months from the year column when subtracting the child's birth date from the date on which the measurements are taken.

4. Plot growth measurements by using the Interpolation Method.

Plotting Interpolation Method:

a. Birth - 36 Month Growth Chart - Calculate exact age (to nearest week) and plot measurement into the space at the point nearest to the age.
b. 2 - 18 Years Growth Chart - Calculate exact age (to nearest month) and plot measurement into space at the point nearest to the age.

5. To plot the length or height for age and weight for age charts:

a. Follow a vertical line at the appropriate age.

b. Using a straight-edge, line up as closely as possible to the measured length or height and weight and mark the point where the two (2) lines intersect.

c. Write the date above the point.

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Appendix L (cont.)
6. To plot the length or height/weight chart:
a. Follow a vertical line at the point of the correct length or height.
b. Using a straight-edge, line up as closely as possible to the weight and mark the point where the two (2) lines intersect.
c. Write the date on the point.
7. To plot Body Mass Index (BMI) for age:
a. Follow a vertical line as near as possible to the appropriate age.
b. Using a straight-edge, line up as closely as possibly the measured BMI and mark the point where the two (2) lines intersect.
8. To plot an infant's head circumference:
a. Follow a vertical line as near as possible to the appropriate age.
b. Using a straight-edge, line up as closely as possible the measured head circumference and mark the point where the two (2) lines intersect.
9. Calculating Gestation-Adjusted Age:
a. Document the infant's gestational age in weeks. (Mother/caregiver can self report, or referral information from the medical provider may be used.)
b. Subtract the child's gestational age in weeks from 40 weeks (gestational age of term infant) to determine the adjustment for prematurity in weeks.
c. Subtract the adjustment for prematurity in weeks from the child's chronological postnatal age in weeks to determine the child's gestation-adjusted age.
d. For WIC nutrition risk determination, adjustment for gestational age should be calculated for all premature infants for the first 2 years of life.

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Appendix L (cont.) Example:
Randy was born prematurely on March 19, 2001. His gestational age at birth was determined to be 30 weeks based on ultrasonographic examination. At the time of the June 11, 2001 clinic visit, his chronological postnatal age is 12 weeks. What is his gestation-adjusted age?
30 = gestational age in weeks 40 30 = 10 weeks adjustment for prematurity 12 10 = 2 weeks gestation-adjusted age
Measurements would be plotted on a growth chart as a 2-week-old infant.
10. Plotting for Prematurity:
For all premature infants and children <24 months plot adjusted and actual age.
a. Infant Plot- (weight/age, Length/age, length/weight)
b. Child Plot- (weight/age, height/age, BMI)
11. The formula for calculating BMI for age is:
[weight (lb.) y height (in.) y height (in.) x 703]
This can be calculated on a hand-held calculator or by computer systems in the district. Once calculated, BMI must be rounded to one decimal point. A reference for converting fractions to decimals and guidance for rounding to one decimal point follows.

Reference for Converting Fractions to Decimals: 1/8 = .125
2/8 or = .25 3/8 = .375
4/8 or = .5 5/8 = .625
6/8 or = .75 7/8 = .875

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Attachment CT-6 (cont'd)

Guidance for Rounding to One Decimal Point:

Appendix L (cont.)

When calculating Body Mass Index (BMI) round the final answer to one decimal point. To do this you will round up to the next number if the second number past the decimal point is five or greater and you will round down if the second number past the decimal point is four or less.

Example: If the final BMI calculation equals 17.158829, the BMI would be 17.2

If the final BMI calculation equals 17.14829, the BMI would be 17.1

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Appendix M
USE AND INTERPRETATION OF THE GROWTH CHARTS
PLOTTING
1. Standing height and weight must be plotted on the 2-18 Years growth charts. 2. Recumbent length and weight must be plotted on the 0-36 Months growth charts. 3. When a measurement cannot be plotted, a notation to this effect must be noted in the
health record or on the growth chart. This measurement may not be used as a risk criterion. See the following example:
Standing height is measured on a 26-month old child. The child is 34 7/8 inches tall. Two options may be taken:
a. Re-measure the child on the recumbent board, and plot length on the 0-36 months growth chart; OR
b. Make a notation in the health record that the height of the child cannot be plotted on the 2-18 years growth chart.

INTERPRETATION
1. Pattern of growth can only be interpreted when two sets of measurements are plotted on the same growth grid. If one set of measurements are plotted on the 0-36 months growth charts and the next set of measurements on the 2-18 years growth charts, these measurements cannot be used to interpret the pattern of growth of the child.

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Appendix N

FOOD SOURCES OF VITAMIN A

Food Source
Apricots canned dried raw

Serving Size
3 halves 10 halves 3 medium

Bok Choy

1 cup

Broccoli cooked raw

1 cup 1 cup

Carrots cooked raw

1cup 1 medium

Cantaloupe, cubed

1 cup

Endive, raw

1cup

Greens, fresh, cooked

beet

1cup

collards

1cup

kale

1cup

turnip

1cup

spinach

1cup

Liver, beef

3 ounces

Mango, raw

1 medium

Papaya, raw

1 medium

Parsley, chopped

1cup

Peaches canned, juice pack raw dried

1 cup 1 medium 10 halves

Persimmon, raw

1 medium

Pumpkin, canned

1cup

Sweet Potato, baked

1 medium

Watercress, raw

1cup

Winter Squash, baked

1cup

*Micrograms of retinol equivalent: rounded to the nearest 10

Vitamin A (mcg Retinol)* 140 250 280
110
110 680
1920 2030 520
50
370 350 480 400 740 10,600 810 620 160
100 50 280 360 2690 2490 80 240

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Appendix O

FOOD SOURCES OF VITAMIN C

Food Source

Serving Size

Broccoli, chopped cooked raw

1/2 cup 1/2 cup

Cantaloupe, raw

1 cup, pieces

Green Pepper

1/2 medium

Grapefruit juice**, from concentrate raw

1/2 cup 1/2 medium

Mango, raw

1 medium

Orange juice**, from concentrate raw (navel)

1/2 cup 1 medium

Strawberries, raw

1 cup

Tomato, raw

1 medium

*Milligrams Vitamin C: rounded to nearest 10 **Items distributed through the Georgia WIC Program.

Vitamin C (mg)*
60 40 70 40
40 50 60
50 80 90 20

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Selected Food Sources of Folate and Folic Acid

Food Source / Serving Size

Micrograms (g)

*Breakfast cereals fortified with 100% of the DV, cup

400

Beef liver, cooked, braised, 3 ounces

185

Cowpeas (blackeyes), immature, cooked, boiled, cup

105

*Breakfast cereals, fortified with 25% of the DV, cup

100

Spinach, frozen, cooked, boiled, cup

100

Great Northern beans, boiled, cup

90

Asparagus, boiled, 4 spears

85

*Rice, white, long-grain, parboiled, enriched, cooked, cup

65

Vegetarian baked beans, canned, 1 cup

60

Spinach, raw, 1 cup

60

Green peas, frozen, boiled, cup

50

Broccoli, chopped, frozen, cooked, cup

50

*Egg noodles, cooked, enriched, cup

50

Broccoli, raw, 2 spears (each 5 inches long)

45

Avocado, raw, all varieties, sliced, cup sliced

45

Peanuts, all types, dry roasted, 1 ounce

40

Lettuce, Romaine, shredded, cup

40

Wheat germ, crude, 2 Tablespoons

40

Tomato Juice, canned, 6 ounces

35

Orange juice, chilled, includes concentrate, cup

35

Turnip greens, frozen, cooked, boiled, cup

30

Orange, all commercial varieties, fresh, 1 small

30

*Bread, white, 1 slice

25

*Bread, whole wheat, 1 slice

25

Egg, whole, raw, fresh, 1 large

25

Cantaloupe, raw, medium

25

Papaya, raw, cup cubes

25

Banana, raw, 1 medium

20

Appendix P
% DV^
100 45 25 25 25 20 20 15 15 15 15 15 15 10 10 10 10 10 10 10 8 8 6 6 6 6 6 6

* Items marked with an asterisk (*) are fortified with folic acid as part of the Folate Fortification Program. ^ DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for folate is 400 micrograms (g). Most food labels do not list a food's magnesium content. The percent DV (%DV) listed on the table indicates the percentage of the DV provided in one serving. A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.

Sources: U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient Database
for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/cgibin/nut_search.pl

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FOOD SOURCES OF IRON

Food Source

Serving Size

Iron Fortified Breakfast Cereal*

cup

Canned Clams

1/3 cup

Cooked Oysters

3 oz

Blackstrap Molasses

1 Tbsp.

Liver

2 ounces

Baked Beans

1 cup

Spinach

1 cup

Red Meat

3 ounces

Prunes

10 large

Raisins

1/2 cup

Pork

3 ounces

Turkey

3 ounces

Baked Potato with skin

1

Ham

3 ounces

Legumes, cooked*

1/2 cup

Raw Shrimp

3 ounces

Baked Winter Squash

1 cup

Berries

1 cup

Turnip or Collard Greens

1 cup

Liverwurst

1 slice

Chicken

3 ounces

Fish

3 ounces

Prune Juice

1/3 cup

*Items distributed through the Georgia WIC Program.

Attachment CT-6 (cont'd)
Appendix Q
Iron (mg) 8-18 11 7 5 5 5 4 3 3 3 3 3 3 2 2 2 2 1.5 2 1.5 1 1 1 1

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Appendix R

MILK GROUP

FOOD SOURCES OF CALCIUM

250 mg

150-249 mg

Milks - 1 cup Whole - 291 mg 1% lowfat - 300 mg 2% lowfat 297 mg Skim - 302 mg Buttermilk - 285 mg Chocolate 284 mg Malted - 348 mg
Swiss Cheeses 272 mg Ricotta, part skim, c - 337 mg Milkshakes - 1 cup
Chocolate 397 mg Vanilla 457 mg Yogurt, lowfat - 1 cup Plain 415 mg Flavored 380 mg Fruit 345 mg

Cheeses - 1 oz. American, processed, 174 mg Blue 150 mg Brick 191 mg Caraway 204 mg Cheddar 204 mg Colby 194 mg Edam 207 mg Monterey 212 mg Mozzarella, part skim 183 mg Muenster 203 mg
Cheese food American, processed, 163 mg Swiss, processed 205 mg

75-149 mg
Cottage Cheese, 2% Lowfat, c, 75 mg Frozen desserts c
Ice cream 88 mg Ice milk, hardened, 88 mg Ice Milk, soft serve, 137 mg Pudding, 133 mg

MEAT/PROTEIN GROUP

Sardines, with bones, 3 oz, 372 mg Tofu, firm processed with calciumsulfate, 4 oz, 250-765 mg

Salmon, with bones 167 mg. - 3 oz Sesame seeds 2 TB, 176 mg.

Beans, dried, cooked, 90 mg. - 1 c Oysters, 7-9, 113 mg Shrimp, canned, 3 oz, 100 mg Tofu, soft, c, 145 mg Tahini (sesame butter) 2 TB, 128 mg. Soybeans, 8 oz, 64 mg Soy beverage, 8 oz, 64 mg Almonds, 1 oz, 75 mg

VEGETABLE GROUP

Cooked, 1 cup Collards, 357 mg Rhubarb, 348 mg Spinach, 278 mg Bok Choy, 252 mg

Cooked, 1 cup Kale, 200 mg Mustard greens, 200 mg Turnip greens, 249 mg

Cooked, 1 cup Okra, 176 mg Broccoli, 90 mg

FRUIT

Figs, dried or fresh 5 med, 135 mg. Papaya, raw 1 med, 72 mg. Sapote, raw 1 med, 88 mg. Tamarind, raw - 1 c, 89 mg.

GRAIN GROUP

Waffle, 7" diameter, 179 mg

Cornbread, 2" square , 94 mg Pancakes, 2-4" diameter, 116 mg

"OTHERS" Category fats, sweets, alcohol

Molasses, Blackstrap, 2 Tbsp., 274 mg

COMBINATION FOODS: Foods made with ingredients from more than one food group

Cheese pizza, of 14" pie, 332 mg

Macaroni and cheese, c c, 181 mg Soups made with milk - 1 c
Cream of mushroom , 191 mg Cream of tomato, 168 mg Taco, beef, 174 mg

Chili con carne with beans, 1 c, 82 mg Custard, baked, c, 148 mg Spaghetti, meatballs, tomato sauce, and cheese, 1 c, 124 mg

Sources:

(1) Pennington, JAT. Bowes & Church's Food Values of Portions Commonly Used. 16th edition. Philadelphia, PA: J.B. Lippincott Co.; 1994. (2) Georgia Dietetic Association Diet Manual. Georgia Dietetic Association, Inc. Fourth edition, 1992. (3) National Osteoporosis Foundation 1991.

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Appendix S

Herbs
Chamomile
Ginseng Mandrake Pennyroyal oil
Sassafras Tonka beans, melilot, sweet woodruff (tea) Devil's claw root
Ginger root tea

HERBS: THEIR USE AND POTENTIAL RISKS

Use

Risks

Relaxant

May cause allergic reaction (up to anaphylactic shock in allergic individuals).

Health food remedy

Painful, swollen breasts

Sold falsely as Ginseng

Contains scopolamine

Abortifacient

Toxicity, teratogenesis, increased risk of medical abortion, hepatotoxin, coma death

Tonic for a variety of unsubstantiated uses

Possible carcinogenesis

Seasonal tonic

Hemorrhage

Abortifacient Morning sickness remedy

Sodium and water retention, hypokalemia, hypertension, cardiac failure/arrest
Unknown - very large doses may cause depression of CNS, and cardiac arrhythmias.

There is insufficient information on many herbs that women may want to use during pregnancy and lactation. Herbs have been used as remedies for years and in many cases some may be beneficial. The problems that might arise may be dose related, which could affect the fetus and growing infant. A safe level or dangerous level is generally not known for use in pregnancy and lactation; avoidance of most herbs is usually the best practice. In addition to the herbs listed above, the following herbs are recommended NOT to be used during pregnancy and lactation:

Angelica Black Cohosh Blessed Thistle Calendula Dong Quai

Elecampane Gotu kola Juniper Berries Motherwart Myrrh

Sources:

Dimperio, Diane: Florida Department of Health and Rehabilitative Services, Florida's Guide to Maternal Nutrition, 1986. Tenney, Louise: Today's Herbal Health, 3rd Edition, Woodland Books, Utah, 1992. Tyler, Varro E.: The Honest Herbal, 3rd Edition, Pharmaceutical Products Press, New York, 1993.

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Attachment CT-6 (cont'd)

KEY FOR ENTERING WEEKS BREASTFED

Appendix T

The number of weeks breastfed must be manually entered when completing paper WIC Assessment/Certification Forms and paper Turnaround Documents for:

- Breastfeeding women: initial and six month certification visits - Postpartum, non-breastfeeding women: certification visit - Infants: initial certification and mid-certification nutrition assessments - Children: initial certification and subsequent certification, until the answer is "No"

Length of time breastfed must be entered in weeks (two-digit). When the answer to the question "How long have you breastfed this infant?" OR "How long has this infant breastfed?" is given in days or months, use the following key to determine appropriate codes.

I. Codes to Enter When Breastfeeding is Given in Days

Convert Days to Weeks

Fewer than 7 days

= 00 weeks

7 - 13 days

= 01 week

14 20 days

= 02 weeks

21 27 days

= 03 weeks

28 34 days

= 04 weeks

35 41 days

= 05 weeks

42 48 days

= 06 weeks

Source: Georgia WIC Program ETAD Change Number 08-12b, 2008.

II. Codes to Enter When Breastfeeding is Given in Months

1 month

= 04 weeks

12 Months

= 52 weeks

2 months

= 08 weeks

13 Months

= 56 weeks

3 months

= 13 weeks

14 Months

= 61 weeks

4 Months

= 17 weeks

15 Months

= 65 weeks

5 Months

= 22 weeks

16 Months

= 69 weeks

6 Months

= 26 weeks

17 Months

= 74 weeks

7 Months

= 30 weeks

18 Months

= 78 weeks

8 Months

= 35 weeks

19 Months

= 82 weeks

9 Months

= 39 weeks

20 Months

= 87 weeks

10 Months = 43 weeks

21 Months

= 91 weeks

11 Months = 48 weeks

22 Months

= 96 weeks

22.5 Months + = 98 weeks or more

Source: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic

Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and

Human Services, Public Health Service. February 2000.

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Attachment CT-6 (cont'd)

Appendix U
Infant Formula Preparation
GENERAL INFORMATION
1. Before starting, wash hands with soap and water. Rinse well.
2. Wash bottles and nipples using brushes made for bottles and nipples. Wash caps, rings and preparation utensils such as spoons, pitchers, etc. Use hot soapy water. Rinse well.
3. Squeeze clean water through the nipple holes to be sure they are open.
4. Put the bottles, nipples, caps and rings and other utensils in a pot and cover with water. Heat on the stove, bring to a boil; boil for 5 minutes. Remove from heat and let cool. OR Put all items in a properly functioning dishwasher and run it at the normal temperature (not the low or economy temperature setting).
5. The most important time to boil bottles, nipples and formula preparation items for the infant is through 3 months of age. Also, the most important time to boil the water used in formula preparation is through 3 months of age. If there is any doubt about the safety of the water supply or the cleanliness of the home, then continue to sterilize the equipment and to boil the water used in formula preparation.
6. Prolonged boiling of water (greater than 5-6 minutes) is not recommended because some trace contaminates in the water such as lead, nitrates, or even trace minerals may concentrate in the boiled water as the liquid water is reduced.
7. Do not feed an infant a bottle left out of the refrigerator for more than 2 hours.
8. For infants who prefer a warmed bottle, hold the bottle under warm running tap water. Shake well and test the temperature before giving to the infant. Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in serious burns to the infant.
9. When using formula:
x Check the formula's expiration date prior to use. Do not use if the date has passed. x Avoid using cans of infant formula that have dents, leaks, bulges or puffed ends or rust
spots.

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Appendix U (cont.)

Infant Formula Preparation
9. (Cont'd) x Store cans of infant formula in a cool place, indoors. Do not store in vehicles, garages or outdoors. x For more information, see the following references: i Infant formula cans - commercial brands. i United States Department of Agriculture, Food and Nutrition Service. Infant Nutrition and Feeding, a Reference Handbook for Nutritional Health Counselors in the WIC and CSF Programs. FNS-288, September 1993. USDA, FNS, Alexandria, Virginia 22302-1594. (U.S. Gov. Printing Office: 1994-0-360-395 QL.3).

PREPARATION FROM CONCENTRATED LIQUID FORMULA

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Heat water for formula on stove to a rolling boil; let cool. 3. Wash top of the can with soap and water; rinse well. Wash the can opener. 4. Shake can well before opening. 5. Open can and pour formula into a clean bottle using ounce markings to measure amount of
formula. Add an equal amount of the cooled boiled water. Example: For 4 ounces of concentrated formula poured into the bottle, add 4 ounces of water. Shake or stir again. 6. To store: cover container or bottles and refrigerate. Use within 48 hours. If more than one bottle is prepared, put the nipples in upside down on each bottle. Cover the nipple with a cap and screw on the ring. 7. After feeding, throw away any formula left in bottle or cup, as this can contain germs.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

PREPARATION OF READY-TO-FEED FORMULA

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Wash top of the can with soap and water; rinse well. Wash the can opener. 3. Shake can very well. Open with a clean punch-type can opener. 4. Pour the amount of ready-to-feed formula for one feeding into a clean bottle.

Note: Do not add water or any other liquid to this formula.

5. Attach nipple and cap. Shake well again and feed infant.

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Attachment CT-6 (cont'd)

Appendix U (cont.)

Infant Formula Preparation

6. If more than one bottle is prepared, put the nipples in upside down on each bottle. Cover the nipple with a cap and screw on the ring. Refrigerate. If formula is left in opened can, cover and refrigerate. Use within 48 hours. Shake can again before pouring; or shake bottles before serving.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

Preparation from Powdered Formula

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Heat water for formula on stove to a rolling boil; let cool to a warm temperature. 3. Remove plastic lid from can; wipe it off if dusty. Wash top of can with soap and water; rinse
well and dry it. Wash can opener. Do not let water get into the can. 4. Pour the warm water into the bottle(s). Use only the scoop that comes with the formula can
(8.7 gm). The scoop should be totally dry before scooping out the powdered formula. Add 1 level scoop of the powdered formula for each 2 oz of warm water in the bottle(s). Example: If 8 ounces of water is poured in the bottle, then 4 level scoops of formula should be added. 5. Put nipples and rings on bottle and shake well. If feeding immediately, check temperature and then feed. After feeding, throw away formula left in bottle or cup, as this can contain germs. 6. Store filled bottles in refrigerator and use within 48 hours. Put a clean nipple upside down on each bottle. Cover the nipple with a cap and screw on the ring. 7. Do not store can containing the dry powdered formula in the refrigerator. Keep it covered and store in a cool, dry place; avoid temperature extremes. Use can within one month after opening.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

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Attachment CT-6 (cont'd)

CONVERSION TABLES AND EQUIVALENTS

Appendix V-1

I. TABLE OF EQUIVALENTS
3 teaspoon (tsp.) 2 Tbsp. 8 oz. 16 Tbsp. 2 c. 2 pts. 4 c. 4 qts.

= 1 Tablespoon (Tbsp.) = 1 ounce (oz) = 1 cup (c.) = 1 c. = 1 pint (pt.) = 1 quart (qt.) = 1 qt. = 1 gallon (gal.) = 128 oz.

II. METRIC SYSTEM

A.

APPROXIMATE WEIGHTS/MEASURES

20 drops 1 ml. 1 ml. 1 tsp. 1 Tbsp. 1 oz., fluid 1 cup, fluid 1 oz., weight 1 c., weight 1 pound (lb.) 2.2 lbs. 33 oz. 1.1 qts.

= 1 milliliter (ml.)
= 1 gram (g.)
= 1 cubic centimeter (cc)
= 5 ml. = 5 cc = 5 g.
= 15 ml. = 15 cc = 15 g. = 30 ml. = 30 cc = 240 ml. = 28.35 g. (approx 30) = 240 g. = 453.6 g. = 1 kilogram (kg.) = 1 liter (L.) = 1000 ml = 1 liter

B.

WEIGHTS

1 milligram 1 gram (g) 1 kilogram

= 1000 micrograms (mcg) = 1000 mg. = 1000 g.

C. References:

CONVERSIONS
To convert ounces to grams multiply by 30. To convert grams to ounces divide by 30. To convert pounds to kilograms divide by 2.2. To convert kilograms to pounds multiply by 2.2. To convert inches to centimeters multiply by 2.54.
Georgia Dietetic Association, Inc., Diet Manual, 4th edition, 1992.

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Attachment CT-6 (cont'd)

Appendix V-2 APPROXIMATE METRIC AND IMPERIAL EQUIVALENTS

Useful approximate metric and imperial equivalents

1 cm = 0.39 in 1 meter = 1.1 yd.

1 in = 2.54 cm 1 ft = 30.48 cm

To convert centimeters to inches Divide the length in centimeters by 2.54. Example: The average newborn infant measures 50.89 cm:
50.89 cm: 2.54 cm/in = 20 in To convert inches to centimeters Multiply the length in inches by 2.54 Example: The average newborn infant measures 20 in:
20 in x 2.54 cm/in = 50.8 cm

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Attachment CT-7

MEASURING LENGTH
Age:
Birth to 24 months. 24-36 months, if proper position to measure stature cannot be achieved or with children less than 32 inches in stature.
Material/Equipment:
Recumbent length board with fixed headboard and movable footboard, both at right angles; marked in increments of 1/8 inch.
x Two (2) people required.
Procedure:
1. Check to be sure that moveable foot piece slides easily and the headboard is at the zero mark.
2. Remove headgear, shoes and bulky clothing. Instruct caretaker to apply gentle traction to ensure that the child's head is firmly against the headboard so that the eyes are pointing directly upward.
3. With the child positioned so that the shoulders, back and buttocks are flat along the center of the board, the measurer should hold the child's knees together, gently pushing them down against the board with one hand to fully extend the child. With the other hand the measurer should slide the footboard to the child's feet until both heels touch the foot piece. Toes should be pointing directly upward.
4. Recheck head placement. Immediately remove the child's feet from contact with the footboard with one hand, while holding the footboard securely in place with the other hand.
5. Measure length in inches to the nearest 1/8 inch. Repeat the measurement sliding footboard away and starting again until two readings agree within 1/4 inch.
6. Record the second reading promptly.

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Attachment CT-8

EQUIPMENT MAINTENANCE
1. A yearly calibration of scales is required for proper usage. To arrange for your equipment to be calibrated, please contact a scale company licensed by the Georgia Department of Agriculture for service or each local agency/clinic may calibrate its scales by using the Procedures for Testing Scales developed by the Georgia Department of Agriculture.
Georgia Department of Agriculture Fuel and Measures Division Agriculture Building, Room 321 Capitol Square Atlanta, Georgia 30334 (404) 656-3605
Please contact the Office of Nutrition for a list of Licensed Scale Calibration Companies.
2. A yearly calibration of centrifuges and other hematological equipment used to determine anemia status of WIC applicants/participants is recommended. There is no State agency that is responsible for this procedure. Calibration of hematological equipment should follow manufacturer recommendations. Each local agency/clinic should establish a calibration procedure.
The Georgia WIC Program has elected to use special codes to be entered into the hematological data field, when hemoglobin is not determined. Please use the following codes, based on the computer systems in your district.
ATVS: 88:8 Mitchell & McCormick (M&M): 88.8 Athens System: 88:8 DeKalb System: 88:8 Aegis: 88:8
Covansys is set up to accept these values to indicate that no blood work has been performed, and will not send this data to the Centers for Disease Control and Prevention (CDC).
Blood work should not be performed on infants younger than 9 months or age, unless there is a medical reason.

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Attachment CT-8 (cont'd)

In most cases, infants will have blood work performed around 12 months or age (infant status blood work) and then 6 months later (child status blood work). If the child's blood work is normal, blood work does not have to be performed for a year. If the blood work is abnormal, it must be re-checked at each subsequent certification until it becomes normal.
Postpartum, breastfeeding women who have breastfed for 6 months will not have to have blood work performed at their second postpartum WIC certification unless there is a medical reason.
It is recommended that hematological equipment be checked for accuracy (balanced/calibrated) according to a regular schedule, based on usage. Follow the manufacturer's instructions for regular calibration of the equipment for machines that do not perform routine/daily self-calibration tests.

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Attachment CT-9

INSTRUCTIONS FOR USE OF PRENATAL WEIGHT GAIN GRID
1. Record applicant/participant's name.
2. Use "Body Mass Index Table" (Attachment CT-10 or CT-11) to determine if the applicant is Normal Weight, Underweight for Height or Overweight for Height, using pre-pregnancy weight. Select the weight curve, which represents the prenatal woman's weight status. If she is pregnant with twins, use the "Twins" chart regardless of her weight status.
3. Enter height in inches without shoes, if not recorded in participant's health record.
4. Use Weight History chart, if information is not recorded in participant's health record.
5. Enter pre-pregnancy weight as indicated. Enter date and weight at each visit.
6. Plot today's weight using the following steps:
a. Record the pre-pregnancy weight at the initial point of the selected weight curve, which is located on the left side of the grid at zero point. From the chart or gestation calculator, determine the completed weeks of gestation.
b. Using the gain (or loss) in weight from the pre-pregnancy weight baseline and the completed gestational weeks (this visit) place an X on the point at which these two lines meet.
c. If the patient does not know her pre-pregnancy weight, or if the weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated completed gestational week. Let this be a beginning point to plot future weights. Indicate that this weight is an estimate by writing "estimate" vertically on the grid next to the X. Use the "Normal" weight curve unless it is very obvious that the prenatal woman was overweight or underweight prior to gestation. Document this observation in the health record.
d. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid.

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Attachment CT-10

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

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GA WIC 2010 PROCEDURES MANUAL

Attachment CT-11

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT

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Attachment CT-12

SIGNED STATEMENT OF INCOME, RESIDENCY AND IDENTIFICATION

I, Parent/Guardian

, cannot come in to apply for WIC for my

child(ren) permission to

Name(s)

. I have given

application. Proxy Name

to file my

The requested documentation listed below is attached. The number of people in my

family is

("Family" means related or non-related individuals living together),

and the monthly household income is ____________.

_________________________________

Parent, Guardian or Caretaker's Signature

Date

The proxy who comes with the child for the recertification appointment must have: 1. This Form; 2. The participant's WIC ID Folder; 3. Parent/guardian or participant's current Medicaid or Food Stamp Letter or
Card; 4. If not eligible for Medicaid, Proof of your income (e.g., Pay stub); 5. Proof of your residency; 6. Proxy Identification; 7. Knowledge of the child's health and diet.

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the Georgia WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/
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Attachment CT-13

GEORGIA WIC PROGRAM INCOME ELIGIBLE GUIDELINES

Household Size 1................ 2................ 3................ 4................ 5................ 6................ 7................. 8................. 9................. 10................ 11................ 12................ 13................ 14................ 15................ 16................

Supplemental Chart for Family Size Greater Than Eight

(Effective from July 1, 2009 to June 30, 2010)

Reduced Price Meals 185% of Federal Poverty Guidelines

48 Contiguous States

Annual

Monthly

Twice-monthly Bi-weekly

$20,036

$1,670

$835

$771

26,955

2,247

1,124

1,037

33, 874

2,823

1,412

1,303

40,793

3,400

1,700

1, 569

47, 712

3,976

1,988

1, 836

54, 631

4,553

2,277

2,102

61,550

5,130

2,565

2,368

68,469

5,706

2,853

2,634

75,388

6,283

3,142

2,900

82,307

6,859

3,430

3,166

89,226

7,436

3,718

3,432

96,145

8,013

4,007

3,698

103,064

8,589

4,295

3, 964

109,983

9,166

4,583

4,231

116,902

9,742

4,871

4,497

123,821

10,319

5, 160

4,763

Weekly $386 519 652 785 918 1,051 1,184 1,317 1,450 1,583 1,716 1,849 1,982 2,116 2,249 2,382

Each Add'l Family Member, add

+$6,919

+$577

+$289

+$267

+$134

Revised 4/3/09

CT-233

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-14

GEORGIA WIC PROGRAM NOTICE OF TERMINATION / INELIGIBILITY / WAITING LIST

DATE: _______________________________

NAME:

DATE OF BIRTH:

ADDRESS:

CITY/ZIP CODE:

PHONE NUMBER:

TERMINATION/INELIGIBILITY SECTION:
You are not eligible for the WIC Program because you:
You are being terminated from the WIC Program because you:
______ have an income that is too high for the WIC Program. ______ do not live in the area served by this WIC Program. ______ are not pregnant, postpartum, or breastfeeding woman; child under five (5) years. ______ do not have a medical/nutritional health problem. ______ did not return to the clinic for your recertification appointment on _________________________ (date). ______ did not pick-up your food vouchers for two (2) months. You will be terminated on
______________________________ (date). Other _______ Fund are not available to serve postpartum non-breastfeeding women.
_______ ________________________________________________________.

SUSPENSION SECTION:
You are being suspended from the WIC Program for three (3) months because you broke the following WIC Program rule(s) WAITING LIST SECTION:
You are being placed on a waiting list. Funds are not available to serve priority(ies)______________ . You are in priority___________________.
x You may still receive nutritional education and other services provided by the Health Department. x If you need information or would like to discuss this decision, please contact the WIC Program at the address below:
FAIR HEARING SECTION:

You have a right to a fair hearing if you do not agree with the reason for your termination/ineligibility or waiting list placement. A request

for a fair hearing must be made within 60 days of the date of this notice. Fair hearing requests should be addressed to:

___________________________________________________________________

WIC PROGRAM

___________________________________________________________________________

ADDRESS

_____________________________________________/______________________________

CITY/ZIP CODE

PHONE NUMBER

____________________________________
SIGNATURE/PARENT/CARETAKER/GUARDIAN

____________________________________
WIC RESPRENTATIVE SIGNATURE/TITLE

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."

If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-234

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-15

EL PROGRAMA WIC DE GEORGIA NOTICIA DE DECONTINUACIN / INELIGIBILIDAD /LISTA DE ESPERA
Fecha: ______________________

NOMBRE:

FECHA DE NACIMIENTO:

DIRECCION:

CIUDAD / CODIGO POSTAL

NUMERO DE TELFONO:

SECCIN DE DESCONTINUACION / DESCUALIFICACION:
Usted no es seleccionada para el programa WIC porque:
Usted ha sido descualificada del programa WIC porque:
_______ Tiene un ingresso muy alto para el Programa WIC _______ No vive en el area servida por el Programa WIC _______ No es una mujer embarazada, acaba de dar a luz, esta dando pecho a su bebe; o tiene un
nio (a) menor de (5) os de edad. _______ No tiene problemas de salud o nutricin _______ No regreso a la clinica para su cita de qualificacin el _______________________ (fecha). _______ No recogi sus cupones para comida por 2 meses. Usted ser descualificada el _______ ____________________________ (fecha).
Otro _________ los fondos no son disponible para servir a mujeres desups del parto no amamantando.

SECCIN DE SUSPENCION:

Usted ha sido suspendida del Programa WIC por tres (3) meses porque rompio la(s) siguiente(s) regla(s)

SECCIN DE LISTA DE ESPERA:

Usted ha sido puesta en la lista de espera. No hay fondos disponibles para servir la prioridad ____________________. Usted esta en la proirdad ________________________________ x Usted puedo recibir education nutritiva y otros servicios provistos por el Departamento
de Salud.
x Si necesita ms informacin o quisiera discutir esta decision, por favor llame a la oficina del Programa WIC a la direccin abajo:

SECCIN DE JUICIO IMPARCIAL:

Usted tiene derecho a un juicio imparcial si no esta de acuerdo con la razon para la seleccin de su

puesto en al Noticia de Decontinuacin / Ineligibilidad / Lista de Espera. La peticin para un juicio

imparcial tiene que hacerce por escrito antes de 60 das a partir de la fecha de esta notificacin. La

peticin debe ser dirigida a:

_______________________________________________________________

PROGRAMA WIC

_______________________________________________________________

DIRECCION

_______________________________________________________________

CIUDAD / CODIGO POSTAL

# DE TELEFONO

_______________________________________

_________________________________

Firma del Participante / Padre o Madre

Firma del Representante

"De acuerdo con la ley Federal de EEUU y la poltica del Departamento de Agricultura, esta institucin esta prohibida a discriminar por raza, color, origen nacional, sexo, edad o incapacidad.
Para hacer una queja de discriminacin, escriba a USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame al (202) 720-6382 o (800) 795-3272 (TTY). El USDA es un proveedor y empleador que ofrece igualdad de oportunidades."
Si usted tiene algun comentario sobre el programa de Georgia WIC, por favor visite el sitio de Internet siguiente: http://health.state.ga.us/programs/wic/

CT-235

GA WIC 2010 Procedures Manual

Attachment CT-16

CT-236

GA WIC 2010 Procedures Manual

Attachment CT-17

CT-237

GA WIC PROGRAM PROCEDURES MANUAL

Attachment CT-18

CT-238

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-19

CLINIC VOC CARD INVENTORY LOG
GEORGIA WIC PROGRAM
VOC CARD INVENTORY LOG

DISTRICT

CLINIC

DATE RECEIVED

Date Beginning Ending

No.

Card

No.

No. Received No.

Issued

Participants Name (Print)

WIC ID Number

Signature of Parent, Guardian or Caretaker

City State*

Total No. of Cards
on Hand

Staff Initials

Staff Initials

Note: A Physical Inventory of VOC cards must be performed by the local agency and clinics quarterly. One staff member must conduct the inventory (initial the Log) and a second member must verify the accuracy of the inventory (initial the Log also).
* If a migrant is issued a VOC card and is not moving, please place "Not Moving" in the column marked City/State.
CT-239

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-20

DISTRICT

LOCAL AGENCY VOC CARD INVENTORY LOG
GEORGIA WIC PROGRAM VOC CARD INVENTORY LOG

Date Beginning Ending

No.

No.

No.

No. Received Issued

Clinic Name (Print)

Name of Clinic Representative

Total No. Staff of Cards Initials on Hand

Staff Initials

Note: A Physical Inventory of VOC cards must be performed by the local agency and clinics quarterly. One staff member must conduct the inventory (initial the Log) and a second member must verify the accuracy of the inventory (initial the Log).
CT-240

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-21

GEORGIA WIC PROGRAM
VOC CARD AGREEMENT
District ______, Unit ______ would like to have a clinic representative order VOC Cards directly from the Georgia WIC Program
In order to accommodate this request, please complete the VOC CARD FORM, located in the Certification Section of the Georgia WIC Policy and Procedure Manual.

Signed________________________________
Nutrition Services Director

Date_____________

IN SIGNING THIS FORM, I REALIZE THAT IF THE CLINIC REPRESENTATIVE CHANGES, I MUST CONTACT THE GEORGIA WIC PROGRAM TO INFORM THEM OF THE CHANGE.

CT-241

GA WIC 2010 PROCEDURES MANUAL
GEORGIA WIC PROGRAM
VOC CARD FORM

Attachment CT-22

District ____, Unit ____
In an effort to begin sending VOC cards directly to the clinic from the Georgia WIC Program, the following form must be on record at the Georgia WIC Program.
1. Please list the information requested below:

CLINIC NAME/#

# OF VOC CARDS ISSUED
(Three Month Period)

STAFF PERSON
Clinic Representative

2. How many cards do you currently have on hand at the District Office?
CT-242

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-23

WOMEN INFANT AND CHILDREN (WIC) ORDERING FORM

SEND TO:________________________________________________________________

(NAME OF OFFICE)

_________________________________________________________________

(STREET ADDRESS)

_________________________________________________________________

(CITY)

(STATE)

(ZIP CODE)

COUNTY:________________________________
(NAME)
DATE:________________________

__________________________
(NUMBER)

STATUS BOX

BO

BACKORDER DO NOT REORDER

C

QUANTITY CUT

N

NOT STORED AT THE STATE

V VOID PREVIOUSLY SHIPPED M MUST BE PRINTED BY DISTRICT D DISCONTINUED

Name of Form

Form #

Quantity

Description

COMMENTS SECTION: ______________________________________ ______________________________________
ORDERED BY:_____________________________________________ TELEPHONE: ______________________________________________ SIGNATURE OF STATE REPRESENTATIVE: ____________________ DATE:______________
CT-243

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-24

GEORGIA WIC PROGRAM
STATE/DISTRICT/CLINIC TRANSMITTAL FORM
The State/District Clinic Transmittal Form is a three (3) part form used to transmit VOC Cards from the Georgia WIC Branch to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. The Georgia WIC Program will forward orders of VOC Cards within five (5) days of receipt.

State Use Only
District Name/ #:_____________________________________________________________
Clinic Name/ #:______________________________________________________________ Staff Name/Title Making Request:_______________________________________________ Date of Request:___________________________ # of Card(s) Sent:___________________
Signature of Requesting State Staff:______________________________________________ Serial # of Card(s) Mailed: ____________________Mailed To:________________________

Clinic Use Only
Date VOC Card(s) Received:___________________________
Date
# of Card(s) Received:_________________________________
Serial # of Card(s) Received: ________________________to:________________________
Signature of Staff Requesting/Receiving VOC Card(s):
____________________________________________
Signature
Date Copy Sent to State/District Office: ___________________________
Date

CT-244

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-25

MEDICAID INFORMATION

Right from the Start Medicaid (RSM)
What is Right from the Start Medicaid?
RSM provides Medicaid coverage for pregnant women and children under the age of 19. Income limits are higher than those of Temporary Assistance to Needy Families (TANF) and Medically needy programs. Working families may be eligible even if both parents live in the home or if other insurance coverage is in place.

How do I Apply?

Persons should contact their county Department of Family and Children Services (DFCS) or their county health department. Outreach workers will also take applications at other community locations and will make home visits if necessary. RSM staff members are available during nontraditional hours (before 8 a.m. and after 5 p.m., including weekends) so that work, school, and childcare are not a problem.

For more information on application sites, please contact

your local health department or the Right

from the Start Medicaid Project office:

(404) 657-4085.

DHR Georgia Department of Human Resources

CT-245

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-26

THERE IS NO CHARGE FOR WIC SERVICES

Georgia WIC Program Promoting healthy nutrition for Women,
Infants and Children since 1974
1-800-228-9173
"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer." If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/
CT-246

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-27

Georgia WIC Program
VERIFICATION OF RESIDENCY AND/OR INCOME

Household Section:

I, ________________________________________, have the person(s) listed below living with me.
Print Name

Name of WIC Applicant(s): ________________________________ ________________________________

Address: __________________________________ __________________________________

Including the applicant(s) listed above, I have ___________ of people in my family. ("Family" means related or non-related individuals living together.)

I give the above listed applicant(s) permission to bring my family's documentation of income (example: pay stub), residency and ID to the Georgia WIC Program. This information is attached.

__________________________________________________________________________________

Signature

Date

Address:_________________________________________

City: _______________________________State: _________________Zip Code: ________________

Telephone No.:_______________________________

Clinic Section:

This form must be returned on _____________________ to ______________________________

______________________________________________________________________________________

WIC Official

Date

_______________________________________________________________________________

WIC Official

Date Received

WE RESERVE THE RIGHT TO VERIFY THIS INFORMATION, IF NECESSARY.
"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the Georgia WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-247

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-28

GEORGIA WIC PROGRAM
NO PROOF FORM

The Georgia WIC Program requires each applicant to show documentation of identification, residence (address), and income to be eligible for the WIC Program. This form is to be completed by those who cannot get documentation, such as paycheck stub. Please read the following statement before completing this form.

I understand that by completing, signing, and dating this form, I am certifying that the information I am providing below is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received.

1. Completion of this form is for: (circle the appropriate proof (s))

Income

Address Identification

2. Who do you work for?

How much did you make last month?

___________________________________ $_______________________________

List working family members:

How much did they make last month?

___________________________________ $_______________________________

___________________________________ $_______________________________

___________________________________ $_______________________________
(Family means related or non-related individuals living together)

3. Reason for No Documentation: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

List family members applying for WIC: ____________________________________

_____________________________________

____________________________________ (Signature of Applicant)

___________________________ (Date)

___________________________________ (Signature of Clinic Staff)

__________________________ (Date)

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."

If you have a comment about the Georgia WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-248

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-29

FAMILY PLUS MEDICAID CARD

BENEFIT DESCRIPTION

COPAYS ------------------OV $0 SP $0 ER $0 UC $0
SEX RX $0 AFD

RX USE ONLY ---------------------------
| BIN # 600426 | PCN #6F | 1 (800) 433-4893 |
| |

CO-PAY

FamilyPlus*

MEMBER # 403967045P

EFF DATE 02/01/98

GROUP# M00101 BIRTH

MEDICAID OF GA 06/03/94 F (404) 525-0600

*CALL YOUR PCP TO COORDINATE NETWORK

*ATLANTA CHILDREN'S HEALTH

*ALL OF YOUR HEALTHCARE NEED

*The family of health plans that fits.

CT-249

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-30

THE DISCLOSURE STATEMENT

All Health Department Staff who performs WIC services must complete this form.

County_______________________

Name (Please print)__________________________, Title__________________

Are you a WIC Participant? ________Yes ________No

Do any of the following relatives or household members participate in the WIC Program?

Children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, in-laws or any person who lives in your household.

_________Yes

__________No

Name of your relative or household member Relationship* Date of Cert.

(If more space is needed, list on back) I certify that the above information is correct.

_______________________________________
Signature/Title

_____________________
Date

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."

If you have a comment about the Georgia WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-250

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-31

GEORGIA WIC PROGRAM
INCOME CALCULATION FORM
(This form must be completed if applicant does not qualify for Adjunctive eligibility)
WIC ID NUMBER: _______________________________

Last

First

Middle Initial

Date of Birth

NAME

___________________________________________________________________________________________________________

City

Zip Code

ADDRESS__________________________________________________________________________________________________

Documentation of Income must be completed for an applicant who does not qualify for adjunctive eligibility.

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Income Source
__________ __________ __________ __________ __________

Use This Section to Calculate Income Date_______________________
What Is Each Family Member's Income?
(circle one)
$______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly

Other Income Is there other regular income or contributions received by the family (i.e., unemployment, child support)?

__________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly __________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

$________________Total Applicant's Income (Weekly/Bi-Weekly/Monthly/Yearly)

No. In Family_____

IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Income Source
__________ __________ __________ __________ __________

Use This Section to Calculate Income Date_______________________
What Is Each Family Member's Income?
(circle one)
$______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly $______________________ Weekly/Bi-Weekly/Monthly/Yearly

Other Income Is there other regular income or contributions received by the family (i.e., unemployment, child support)?

__________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly __________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

$________________Total Applicant's Income (Weekly/Bi-Weekly/Monthly/Yearly)

No. In Family_____

IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)

I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided is correct, to the best of my knowledge. The income I have given is my total gross income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other health or public assistance agencies to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CARETAKER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (Who assessed income)

Please place this form in the Client's Medical Record behind the Certification Form
"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer." If you have a comment about the Georgia WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/
CT-251

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-32

IDENTIFICATION, RESIDENCY & INCOME PROOF LIST
Help WIC help you!
"Proof of ID, residency and income is needed for each applicant/participant/guardian/caretaker and infant/child". Please call your local WIC department for any questions you may have. Whenever your child, infant or you need be certified for WIC, you must present proof of each of the following categories:
Proof of Identifications (One form of proof required)

Infant: Birth Certificate Confirmation of birth letter Hospital ID bracelet (mom & baby) Immunization Record Military ID Health Records Social Security Card Discharge of hospital papers EVOC/VOC Card (with Additional ID)

Child: Birth Certificate Immunization Record Health Records Social Security Card Military ID EVOC/VOC Card (with Additional ID)

Women: Birth Certificate Driver's License Immunization Record Military ID Health Records Hospital ID bracelet (mom & baby) Social Security Card State ID/School ID EVOC/VOC Card (with Additional ID) WIC ID (Voucher Pick Up Only) Work ID

Proof of Residency (Address) (One form of proof required)

Cable TV Bill

Gas Bill

Electric Bill

Water Bill

Medicaid (address must be visible during swipe or internet access)

Telephone Bill Rent/Mortgage Receipt Health Record

(P.O. Box address is not acceptable)

Proof of Income (Bring proof of Income for each household member)

Alimony Pay Stub Annuities Pensions Basic Allowance from Private Pensions Child Support Payments Public Assistance/Welfare Payments (TANF) Contribution from people Current Tax Return

Rental Income (Net) Dividends or Interest on Bonds Self Employment (Net Income) Estate Income Social Security Financial Records Supplemental Social Security Food Stamps Documentation Trust

Government Retirement Unemployment Compensation Letter from your Employer Unemployment Notice Medicaid Military Retirement Veteran's Payment Monetary Compensation Net Royalties

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."

If you have a comment about the Georgia WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/
CT-252

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-33

LISTA DE IDENTIFICACIN, RESIDENCIA Y COMPROBANTE DE INGRESOS

Ayude a que WIC le ayude!

"Comprobantes de identidad, residencia e ingresos son necesarios para cada solicitante, participante, representante legal, proveerdor de cuidados y para nios y bebs". Favor de llamara a su oficina local de WIC en caso de tener alguna pregunta. Cada vez que su nio(a), infante o usted necesite certificarse para WIC, usted debe presentar comprobantes de cada una de las siguientes categoras:

Infante: Certificado de nacimiento Carta de confirmacin de nacimiento Bracelete de identificacin del hospital (madre y beb) Historial de inmunizaciones Identificacin militar Historial de salud
Tarjeta de Seguro Social Documentos de dada de alta del hospital Tarjetas EVOC/VOC (con identificacin adicional)

Comprobantes de Identificacin

(Se requiere un tipo de comprobante)

Nio(a):

Mujeres:

Certificado de nacimiento

Certificado de nacimiento

Historial de inmunizaciones Licencia de conducir

Historial de salud

Historial de inmunizaciones

Tarjeta de Seguro Social Identificacin militar Tarjetas EVOC/VOC (con identificacin adicional)

Identificacin militar Historial de salud Bracelete de identificacin del hospital (madre y beb) Tarjeta de Seguro Social Identificacin estatal, identificacin escolar Tarjetas EVOC/VOC (con identificacin adicional) Identificacin de WIC (slo para recoger el taln) Identificacin laboral

Comprobantes de Residencia (Direccin)

(Se requiere un tipo de comprobante)

Recibo de televisin por cable Recibo de gas

Recibo de telfono

Recibo de electricidad

Recibo de agua

Recibo de alquiler / pago de

hipoteca

Medicaid (la direccin debe

Historial de salud

ser visible en la corrida o

acceso por internet)

(No se aceptan direcciones a cajas postales o P.O. Box)

Comprobantes de Ingresos

(Traiga comprobantes de ingresos para cada miembro del hogar)

Pensin alimentaria entre

Ingresos por renta (neto)

Retiro gubernamental

cnyuges

Talones de pago

Dividendos o intereses por

Compensacin por desempleo

bonos

Anualidades

Empleo Independiente

Carta del empleador

CT-253

GA WIC 2010 PROCEDURES MANUAL

Attachment 33 (cont'd)

Pensiones Contribucin bsica proveniente de pensiones privadas Pagos de manutencin infantil Asistencia pblica/bienestar Pagos (TANF)
Contribuciones provenientes de personas Declaracin actual de impuestos

(Ingreso Neto) Ingreso estatal Seguro Social
Historial financiero Seguro Social suplementario Documentacin de estampillas alimentarias Fideicomiso

Notificacin de desempleo Medicaid
Retiro militar Pago de Veterano Compensacin monetaria
Regalas netas

"De acuerdo con la ley Federal de EEUU y la poltica del Departamento de Agricultura, esta institucin esta prohibida a discriminar por raza, color, origen nacional, sexo, edad o incapacidad.
Para hacer una queja de discriminacin, escriba a USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame al (202) 720-6382 o (800) 795-3272 (TTY). El USDA es un proveedor y empleador que ofrece igualdad de oportunidades."

Si usted tiene algun comentario sobre el programa de WIC, por favor visite el sitio de Internet siguiente: http://health.state.ga.us/programs/wic/

CT-254

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-34

GEORGIA WIC PROGRAM Thirty (30) Day Certification/Termination Form
This Thirty (30) Day Certification Form allows you to be on the Georgia WIC Program for thirty (30) days only. The certification period will be extended if the required documentation is brought back to the clinic within 30 days and eligibility is confirmed.
DATE_________________________

NAME: ADDRESS: CITY/ZIPCODE:

DATE OF BIRTH: PHONE NUMBER:

_____ You will be terminated from the WIC Program if you fail to bring in the following information by ______________. (date)
Proof of: _____ Family Income or _____Medicaid, TANF or Food Stamp Documentation (check one)

_____ Identification Client

_____ Identification Parent/Guardian

________ Residency

WIC Representative ______________________________________ Date ___________________________
FAILURE TO BRING THIS DOCUMENTATION TO THE HEALTH DEPARTMENT ON OR BEFORE THE ABOVE DATE WILL RESULT IN TERMINATION FROM THE WIC PROGRAM

_____ You are being terminated from the WIC Program because you have been found to be over income.

WIC Representative_____________________________________

Date_____________________

FAIR HEARING SECTION:

You have the right to a fair hearing if you do not agree with the reason for your termination. A

request for a fair hearing must be made within 60 days of the date of this notice. Fair hearing

requests should be addressed to:

_______________________________________________

WIC Program

_______________________________________________

Address

_______________________________________________

City/Zip Code

Phone Number

___________________________________________________ ______________________________________

Participant Signature/Parent/Caretaker/Guardian

WIC Representative Signature/Title

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-255

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-35

Session Date:

Department of Defense WIC Overseas Program
Participant's Name: Participant Profile Report/Verification of Certification Card (VOC)

Address 1:

Gender:

DOB:

Marital:

Participant ID:

Spouse/Parent Guardian Name:

Address 1:

Annual Income:

Sponsor Name:

Sponsor Address 1:

Relationship:

Authorized Proxy:

Encounter Type:

Height:

Weight: BMI:

Nutrition Risks:

Nutrition Education:

Food Prescription ID:

FI One: xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx

Address 2: Education: Unit Phone #: Language:
Address 2: Primary Source:
Sponsor Address 2: UIC:
WIC Site ID: Hematocrit: Priority: Date Provided:
FI Two: xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx

Participant Type: Category: Home Phone: Race/Ethnic: Home Phone: Unit Phone: Econ. Unit: Home Phone #: Unit Phone #: DEROS:
Begin Cert Date: End Cert Date: Date of Measurement: EDD: Health Care Source:
FI Three: xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx

Food Instrument Issued for Dates:

Participant Rights and Obligations:
I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. I understand I have a right to appeal any decision which I am aggrieved. This certification form is being submitted in connection with the receipt of Federal funds. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and federal law. I hereby certify that I am not currently enrolled in any other WICO or WIC Program. I understand that to do so would be deliberate misuse of program benefits and could result in the loss of these benefits.

Participant or Parent/Guardian Signature:

Date:

Competent Professional Authority:

Print Name:

CT-256

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-36

WIC OVERSEAS PROGRAM CONTACTS
(as of April 2001)

x Lakenheath, England

-- Nancy Czarzasty nancy.czarzasty@lakenheath.af.mil

x Yokosuka, Japan

-- Yokosuka Naval Hospital, Honshu, Japan Gina Gagui gaguig@nhyoko.med.navy.mil

x Baumholder, Germany

-- LTC Barbara Fretwell barbara.fretwell@cmtymzil.104asg.army.mil

-- Kadena Air Force Base Theresa Reiter theresa.reiter@kadena.af.mil

-- Camp Foster --- Emily Bartz okibartz@konnect.net

-- Camp Courtney --- Theresa Reiter wicoc@mcbbutler.usmc.mil

-- Camp Kinser --- Emily Bartz okibartz@konnect.net

x Guantanamo Bay, Cuba -- Dana T. Martin dtmartin@gtmo.med.navy.mil

For further questions regarding a WIC Overseas Program contact and/or email address, please visit DoD/Tricare's Web Site at http://www.tricare.osd.mil for updated information or contact:
Choctaw Management/Services Enterprise 2161 NW Military Drive, Suite 308 San Antonio, Texas 78213 Phone: 1-877-267-3728 (toll-free number) Fax: 210-341-3455 Email: jbrewer@cmse.net

CT-257

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-37

PROOF OF RESIDENCY FORM FOR APPLICANTS WITH P.O. BOX ADDRESS
The WIC applicant must complete this form when giving a post office box address:
Directions to House

Participant Signature

Date

Participant Signature

Date

Participant Signature

Date

This form must be filed in the applicant/participant's health record.

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."

If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-258

GA WIC PROCEDURES MANUAL

Attachment CT-38

INCOME VERIFICATION LETTER

Date

Dear Mr/Ms:
It has been brought to the attention of the Georgia WIC Program that the income reported in the clinic may not be accurate. In order to qualify for the Georgia WIC Program, you must meet the income guidelines of the program.
Please bring in proof of family income on your next clinic appointment on ___________ at _____ a.m./p.m. At that time, you may bring either a copy of your most recent pay stub, a letter from your employer verifying your current wages, a copy of your most recent federal tax return, or a verification letter from the local welfare office. Failure to do so will result in termination from the program, an investigation and may require you to pay the State Agency in cash the value of the benefits improperly issued to you or your family member(s).
Sincerely,

__________________ Title
c:

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-259

GA WIC 2010 PROCEDURES MANUAL
GEORGIA WIC PROGRAM INCIDENT/COMPLAINT FORM
District/Unit/Clinic: County: Date of Incident: Date Reported: Follow-up Date:

Person Filing Complaint Name: Address:
Phone: Incident/Complaint:

Participant Information Name: Guardian: WIC I.D. Number: DOB: Phone:

Vendor Information Vendor/Vendor #: Employee Name:
Title: Phone:

Local Agency Resolution:

State WIC Branch Resolution/Comments:
Follow-up Report: SWB Customer Service Coordinator:

CT-260

Attachment CT-39
Type of Complaint: Participant Vendor
Civil Rights Local Agency/State WIC Branch Staff
Local Agency/State WIC Information Staff Name: Phone:
Can Complaint be Closed at Local Agency? Yes No Signature and Title: Date:
Can Complaint be Closed at State WIC Branch? Yes No Signature and Title: Date:
Date:

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-40

GEORGIA WIC PROGRAM How to File a Complaint

If you feel you have been treated unfairly, please let us know by using the information listed below. The WIC Program will assist you as well as notify the proper authorities if necessary.
ANY COMPLAINT You may call the WIC Program about any complaints at the toll free phone number: 1-800-228-9173 and/or write about your complaint to the address below:
WIC Program Policy Unit 2 Peachtree Street, Suite 10-286
Atlanta, GA 30303
DISCRIMINATION AND/OR CIVIL RIGHTS If you feel that you have been discriminated against or that your civil rights have been violated, you may contact the WIC Program by calling the toll free number 1-800-2289173, and/or write about your complaint to the address below:
WIC Program Policy Unit 2 Peachtree Street, Suite 10-286
Atlanta, GA 30303
And/or you may contact the Federal Office of Civil Rights directly by calling the phone number below:
1-800-795-3272 (202) 720-6382 (TTY) and/or you may write the Office of Civil Rights at the address below:
Office of Civil Rights 1400 Independence Avenue, SW
Washington, DC 20250-9140
"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/
CT- 261

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-41

NAME

REQUEST FOR WIC SERVICES LOG PHONE CALLS/WALK-INS

ADDRESS

P/B/PP
Infant/child

Date Service Date Of Re-appointments

Requested Appointment

Prenatal

CT-262

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-42

Georgia WIC Program
Interview Script
The WIC program is a nutrition program for Women, Infants and Children who have nutritional needs and are income eligible. Eligible program enrollees receive:
Nutrition assessment Nutrition education Healthy foods (milk, eggs, cheese, juice, cereal, peanut butter, dried beans or peas, carrots, tuna
and infant formula) Support for breastfeeding moms Referral to other health and social services You may qualify for WIC if you: are pregnant, just had a baby, is breastfeeding a baby, or have small children under age 5; have a moderately low family income, even if you work; and have a documented nutrition-related medical need: and live in the State of Georgia.

The following information is being asked for statistical purposes and the answers will have no effect on the receipt of WIC services

Are you a Migrant?

_________Yes

_________ No

Are you Hispanic/Latino? _________Yes

_________ No

(Yes = A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or origin, regardless of race.)

What is your RACE ?

You may choose more than one race or all that apply.

1._____ White A person having origins in any of the original people of Europe, the Middle East of North Africa.
2._____ Black or African American A person having origins in any of the Black racial groups of Africa.
3._____ Asian A person having origins in any of the original people of the Far East, Southeast Asia, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
4._____ American Indian/Alaska Native A person having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
5._____ Native Hawaiian or Other Pacific Islander A person having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific Islands.
"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 202509410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

CT-263

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-43

Separation of Duty Form/District Office

Type of Certification (Home, Hospital, etc.)

Date of
Certification

Was Any
Information
Missing?
(Cert. , Voucher Receipt, Nutrition Information)

Name of Person who performed
Certification

WIC Coordinator
or Designee's Name

Approved or
Disapproved

Completion Date

(This form must be kept on file for 3 years plus current year)
CT-264

GA WIC 2010 PROCEDURES MANUAL

Attachment CT-44

MILITARY INCOME INCLUSIONS AND EXCLUSIONS

BAH BAS BASE CAREER SEA PAY CLOTHING
COLA FLPP
FLY FSSA
FSP HDP HFP JUMP SDP SEB
SEP SPEC SRB
TDY REBATE TLA FSH OLA SAVE CMAI
UEA

BASIC HOUSING SEPARATE RATIONS BASE PAY CAREER SEA PAY CLOTHING ALLOWANCE
COST OF LIVING ALLOWANCE FOREIGN LANGUAGE PROFICIENCY PAY FLY PAY FAMILY SUBSISTANCE SUPPLEMENTAL ALLOWANCE FAMILY SEPARATION PAY HAZARDOUS DUTY PAY HAZARDOUS FIRE PAY JUMP PAY SPECIAL DUTY PAY SERVICE MEMBER ENLISTMENT BONUS SEPARATION PAY SPECIAL FORCES STANDARD REENLISTMENT BONUS
TEMPORARY DUTY REBATE TEMPORARY LODGING ALLOWANCE FAMILY SEPARATE HOUSING OVERSEAS LIVING ALLOWANCE FOREIGN DUTY PAY CIV CLOTHING MAINT ALLOWANCE
ONE TIME CLOTHING ALLOWANCE FOR WI

DO NOT COUNT TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) DO NOT COUNT TO BE COUNTED
TO BE COUNTED TO BE COUNTED
TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) TO BE COUNTED TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) TO BE COUNTED DO NOT COUNT DO NOT COUNT DO NOT COUNT DO NOT COUNT TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) TO BE COUNTED (DIVIDE BY 12)

CT-265

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52

GA WIC 2010 PROCEDURES MANUAL

Attachment RO-2

GEORGIA WIC PROGRAM

CLAIMANT'S WIC PROGRAM RECORD SUMMARY

SECTION I - IDENTIFICATION

District/Unit

WIC ID #

Applicant/Participant:

Claimant (if different from above):

Address:

Street Number and Name

City

State

Zip Code

Phone Number:

Representative:

Applicant/Participant's Race/Sex: (Circle item #)

Ethnicity: (1) Hispanic or Latino (2) Non Hispanic or Latino

Sex: (1) Male (2) Female

Race: (1) American Indian or Alaskan Native (2) Asian (3) Black or African-American (4) Native Hawaiian or Other pacific Islander (5) White

County:

Date of Request:

Date of Appointment:

Date of Notification:

FOR STATE OFFICE USE ONLY:

Request number:

Date request filed:

Time limits: 7 CFR 246.9(j) Hearing is to be held within three (3) weeks from the date the State or local agency receives the request for hearing. 7 CFR 246.9(k)(3) . The decision is to be issued within 45 days of the date the request for hearing was received by the State or local agency.

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GA WIC 2010 PROCEDURES MANUAL

Attachment RO-2 (cont'd)

SECTION II - TYPE OF AGENCY ACTION OR INACTION

A. Agency Action (Circle item number)

Participation denied/terminated because client:

1. Is not income eligible.
2. Does not live in local program area.
3. Has reached expiration of regulatory eligibility.
4. Is not pregnant, postpartum, breastfeeding or infant/child under five (5) years old.

__________ Date __________ Date __________ Date __________ Date

5. Does not meet nutritional risk criteria.

6. Failed certification appointment on: ____________________.

7. Did not pick up vouchers for two (2) consecutive months.

8. Violated program rules and was suspended for three

(3) months for:

.

9. Is in Priority and program has funds to serve

only Priority(ies)

.

10. Other

.

B. Agency Inaction (Circle item number):

__________ Date __________ Date __________ Date
__________ Date
__________ Date __________ Date

1. Failure of local agency to meet processing standards: (specify) ____________________________________________________________________

2. Other:

(specify)

____________________________________________________________________

____________________________________________________________________

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GA WIC 2010 PROCEDURES MANUAL

Attachment RO-2 (cont'd)

SECTION III - NARRATIVE SUMMARY OF AGENCY'S ACTION OR INACTION AND PRINCIPAL ISSUES INVOLVED IN THE REQUEST FOR HEARING
A. Basis for local agency's action or inaction (specify briefly):

B. WIC regulations applied by local agency:

C. Participant's income eligibility information:

_______________________________ Signature/Title of WIC Personnel

_______________________________ Signature of WIC Coordinator

________________________________ Program Name

________________________________ Address

___________________________________

City

State

Zip Code

_________________________________ Telephone Number

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."
If you have a comment about the WIC Program, please go to the following website: http://health.state.ga.us/programs/wic/

RO-24

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52

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52

GA WIC 2010 PROCEDURES MANUAL

Administrative

TABLE OF CONTENTS
SECTION ONE - FINANCIAL MANAGEMENT Page
I. Agreement with State Agency ............................................................................... AD-1 II. Financial Procedures ............................................................................................... AD-2
A. District Health Agencies .................................................................................... AD-2 B. Non-profit Agencies .......................................................................................... AD-2 C. Unliquidated Obligations .................................................................................. AD-2 D. Year End Funds Obligations ............................................................................ AD-2 III. Funding Requirement .............................................................................................. AD-2 IV. Equipment Inventory ............................................................................................... AD-4
A. Acquisition........................................................................................................ AD-5 B. Status Change .................................................................................................. AD-5 V. Retroactive Benefits and Reimbursements............................................................ AD-6 A. Revenue ............................................................................................................ AD-6 B. Misuse of Funds .............................................................................................. AD-6 VI. Local Agency Collections......................................................................................... AD-6
SECTION TWO STATEWIDE COST ALLOCATION PLAN I. Introduction to WIC Statewide Cost Allocation Plan.......................................... AD-7
Purpose....................................................................................................................... AD-7 Authority.................................................................................................................... AD-7 Background................................................................................................................ AD-7 Public Health Grant-In-Aid Program .................................................................... AD-8 Cost Distribution....................................................................................................... AD-8

GA WIC 2010 PROCEDURES MANUAL

Administrative

Composition of Cost ................................................................................................. AD-9 II. Basic Cost Principles/WIC Allowable Costs ........................................................ AD-9
General Requirements.............................................................................................. AD-9 Components of Federal WIC Grant...................................................................... AD-10 Nutrition Service Administration (NSA) Cost - General .................................. AD-11 Food Cost ................................................................................................................. AD-11 NSA Costs for Clinic Activities............................................................................. AD-11 NSA Costs for Program Management Activities ............................................... AD-13 Unallowable Costs .................................................................................................. AD-13 Cost-Related Compliance Requirements............................................................. AD-14 III. Method for Charging the Cost of Wages and Salaries...................................... AD-14 Structure of Cost Data ............................................................................................ AD-14 Personnel Activity Report...................................................................................... AD-15 Methodology............................................................................................................ AD-15 Definitions of Functions......................................................................................... AD-23 Requirements........................................................................................................... AD-24 Nutrition Services and Administration Cost Categories .................................. AD-25 IV. Method for Charging Salary and Non-Salary Cost............................................ AD-25 Overview .................................................................................................................. AD-25 Lead County Cost Allocation Plan ....................................................................... AD-27 Central Cost Allocation Plan for Counties .......................................................... AD-27 Bases for Distributing Shared Services ................................................................ AD-27 Inequitable Methods of Cost Allocations ............................................................ AD-28 Expensing Equipment Purchases ......................................................................... AD-29

GA WIC 2010 PROCEDURES MANUAL

Administrative

SECTION THREE - PROGRAM ADMINISTRATION I. Retention of Records............................................................................................... AD-30
A. Definition of Records........................................................................................ AD-30 B. Records and Reports - Accessibility of Records ........................................... AD-30 C. Retention Schedule ........................................................................................... AD-30 D. Prior Approval/Duplication of WIC Records .............................................. AD-31 II. WIC Acronym and Logo........................................................................................ AD-33 A. Authority............................................................................................................ AD-33 B. Official Use......................................................................................................... AD-34 C. Special Use ......................................................................................................... AD-34 D. WIC Food Vendors ........................................................................................... AD-34 E. Unauthorized Use ............................................................................................. AD-35 III. Lobbying Restrictions............................................................................................. AD-35 IV. Confidentiality......................................................................................................... AD-35 V. E-Mail and Faxing Confidential Information ..................................................... AD-36 VI. WIC Volunteers and Confidentiality .................................................................. AD-37 VII. Health Insurance Portability and Accountability Act ....................................... AD-38 VIII. Retroactive Benefits and Reimbursements.......................................................... AD-38 IX. Mandatory No-Smoking Policy ............................................................................ AD-38 X. Subpoenas ................................................................................................................ AD-39 XI. Search Warrants ...................................................................................................... AD-40 XII. Program Participation ............................................................................................ AD-41 XIII. Establishing New Clinics/Clinic Changes .......................................................... AD-41 XIV. Clinic Closings......................................................................................................... AD-43

GA WIC 2010 PROCEDURES MANUAL

Administrative

XV. Damaged Formula Report ..................................................................................... AD-44 XVI. Reporting Systems Problems................................................................................. AD-44 XVII. Request for Financial and/or Statistical Data..................................................... AD-44 XVIII. Identification Cards and Food List Orders ......................................................... AD-44 XIX. Clinic/Staff Ratio .................................................................................................... AD-44 XX. Nutrition Service Director Job Description ......................................................... AD-45 XXI. Compliance Reviews .............................................................................................. AD-45 XXII. Medical Nutrition Therapy.................................................................................... AD-46 XXIII. Registered and/or Licensed Dietitian Credentialing Policy for
DCH Division of Public Health ............................................................................ AD-46 XXIV. Conflict of Interest................................................................................................... AD-47 XXV. Renovations ............................................................................................................ AD-48 XXVI. Inter/Intra Agency Agreement .......................................................................... AD-48 XXVII. Patient Flow Analysis ......................................................................................... AD-48 Attachments: AD-1. FFY 2009 Georgia WIC Program Agreement .................................................... AD-54 AD-2. Equipment Status Change Form/Transfer Form & Invoice ........................... AD-58 AD-3. Agreement for Disclosure of Information.......................................................... AD-59 AD-4. Release of Information Form ............................................................................... AD-60 AD-5. Request to Establish New Clinic/Clinic Changes ............................................ AD-61 AD-6. Computer System Issues and Problem Report Form ....................................... AD-62 AD-7. New Site Permission Form................................................................................... AD-63 AD-8. Data Request Form ................................................................................................ AD-64 AD-9. New Clinic Evaluation Report............................................................................. AD-65

GA WIC 2010 PROCEDURES MANUAL

Administrative

AD-10. Staffing Pattern Form............................................................................................ AD-71 AD-11. Nutrition Services Director Job Description ...................................................... AD-72 AD-12. Patient Flow Analysis ........................................................................................... AD-75
A. Option I ............................................................................................................. AD-75 B. Option II ........................................................................................................... AD-79 AD-13. Inter/Intra Agency Agreement ........................................................................... AD-86 Option I ................................................................................................................... AD-87
A. Planned Budget for SFY 2010 ................................................................. AD-90 B. Central Cost Allocation Plan (643) ......................................................... AD-91 Option II.................................................................................................................. AD-92 A. Planned Budget for SFY 2010 ................................................................. AD-94 B. Central Cost Allocation Plan (643) ......................................................... AD-95 AD-14. Financial Reviews.................................................................................................. AD-96 AD-15. WIC Local Agency Funding Formula ................................................................ AD-98

GA WIC 2010 PROCEDURES MANUAL

Administrative

SECTION ONE - FINANCIAL MANAGEMENT
I. AGREEMENT WITH STATE AGENCY Prior to July 1 of each year, all local agencies operating a WIC Program, excluding contracted local agencies, must sign a copy of DCH Master Agreement which included Annex I and submit to the Budget Office (See Attachment AD-1).
District staff receiving WIC funds must: 1. Provide services in accordance with the Child Nutrition Act of 1966, as
Amended by Public Law 108 for the delivery of services for the Women, Infants and Children (WIC) Program. This provider agreement is made pursuant to the Georgia Department of Community Health (DCH) Administration Policy and Procedures Manual, Part II A.I and the United Stated Department of Agriculture/Food and Nutrition Services (USDA/FNS regulations being 7CFR 246. The Georgia WIC Policy and Procedures Manual, the Georgia WIC Program State Plan, the Georgia WIC Program Guidance for Local Agency Planning, and all administered memos. (The aforementioned documents are hereinafter incorporated into the agreement.)

2. Collect and submit accurate client data for WIC participants for the purpose of monitoring program performance. Comply with all federal and state requirements in the collection of program data and make modifications as appropriate or requested within a specified time.

3. Employ appropriate staff to adequately perform WIC responsibilities in accordance with WIC staffing and processing standards, certification requirements, program integrity, and voucher accountability and security.

4. Participate in development of the Georgia WIC State Plan that is annually submitted to USDA. Submit a local agency program plan to the WIC Program by March 31st for inclusion in the annual state plan.

5. Provide WIC Farmer's Market Nutrition Program services according to the federal regulations 7CFR 248 and the state WIC Farmer's Market handbook.

REPORTING REQUIRMENTS:

1. Submit an annual report by March 31st for the previous federal fiscal year (October thru September).

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GA WIC 2010 PROCEDURES MANUAL

Administrative

II. FINANCIAL PROCEDURES

A. District Health Agencies
Adhere to:
Georgia WIC Procedures Manual USDA FNS Instruction 808-1 OMB Circular A-87 and A-102 Grant-in-Aid Policy & Procedure Manual, Parts III.E, Attachment 1 and IX.A, B., from the Department of Community Health. Title 7 Code of Federal Regulations Part 246 (7 CFR 246)

B. Non-profit Agencies
Adhere to the tenets of the negotiated contract and prescribed policies and procedures established by USDA, (7 CFR 246), the WIC Program (Division of Public Health) and DCH.

C. Unliquidated Obligations
USDA requires that Unliquidated Obligations be reported. District Health Agencies are to report these on their Monthly Income and Expense Reports (MIER).

D. Year End Funds Obligations
In order to utilize year-end Nutrition Services Administration (NSA) funds, all purchase orders must be completed, properly dated and forwarded to the vendor prior to September 30th.

III. FUNDING REQUIREMENT
THE LOCAL AGENCY MUST:
1. Implement management controls to track and ensure accountability of program funds, assets and property, in accordance with the WIC Program regulations. A penalty of up to $25,000 may be charged for the misuse or illegal use of program funds, assets or property. This applies to individuals that embezzle, willfully misapply, steal or obtain by fraud, assets or property, whether received directly or indirectly from USDA.
2. Have a central cost allocation plan that has prior approval from DCH, Office of Financial Services.

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GA WIC 2010 PROCEDURES MANUAL

Administrative

3. Ensure that the local agency staff complies with guidelines and procedures for requesting and expending funds awarded to the Local Agency for special projects. As an addendum to this annex, the WIC Program shall outline project specific requirements in the "Local Agency Special Projects Terms and Conditions". Grant funds awarded for special projects shall not be used to supplant existing programs. All equipment purchases made with special projects funds are the property of the Georgia WIC Program and shall be transferred back to the state at the termination of the project.
4. Maintain complete and accurate documentation of allocated funds received and expended, employing General Accepted Accounting Principles (GAAP) and to make these records available for audit upon request of the WIC Program or the Federal Agency; establish budgets for Random Moment Sample Study (RMSS) Cost Pool (301) expenses, direct nutrition education (007) expenses, direct breastfeeding (009) expenses and 100% direct WIC administrative (643) expenses.
5. In case of an audit exception, the Local Agency may be required to repay the Department from the Local Agency's non-participating funds.
6. Federal regulations require the WIC Program to spend 97% of its food grant dollars. Failure to meet this mandate may result in the imposition of a penalty. To be consistent with the federal mandate, each Local Agency will be expected to serve a minimum number of WIC participates as determined by the federal caseload mandate.
7. Request and obtain, through the WIC Program, prior approval for the purchase of computers and /or related hardware and software regardless of cost and for any capital expenditure over $5,000.
8. Complete all monthly Bank Exceptions Reports, and Cumulative Unmatched Redemption (CUR Reports) received from the State EIC Branch or the Data Processing Contractor and return within the specified time. Local agencies will monitor clinics for compliance. Failure to correct the errors on the CUR report when moved to Part Two of the report will require a monetary payback to the WIC Program when the total amount of the redeemed vouchers exceeds $1,000.00.
9. Place all wholly paid WIC employees (100%) into the 301 cost pool.
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GA WIC 2010 PROCEDURES MANUAL

Administrative

10. Ensure that no WIC funds are expended toward a computer system unless the computer system has prior written approval by USDA.

11. The local agency that participates in Using Loving Support to Manage Peer Counseling agrees to the development, operation and evaluation of supervisory clinic staff and Peer Counselors (PC) as prescribed in guidance developed by Best Start Social Marketing. All peer counseling grant funds will be available as grant-in-aid under Program #329. A Peer Counselor must be a current or former WIC participant with prior breastfeeding experience. Preferred candidates should have six (6) months of personal breastfeeding experience. The actual number of peer counselors employed may be determined by the Health Director, as long as the individual Peer Counselor hours do not exceed thirty (30) hours a week. A Peer Counselor must be paid a minimum of ten dollars ($10.00) per hour.

A Peer Counselor must be reimbursed for all approved work related expenses as stated in the Georgia Department of Community Health Travel Regulations. The local Contractors must have available an equal number of additional alternate Peer Counselors. The purpose of alternate Peer Counselors is to have trained replacements immediately available, in event of a Peer Counselor position vacancy. The grant award will include additional funds of ten dollars ($10.00) per hour for the training of the alternate Peer Counselors. Funds from this grant must not be used to supplant existing WIC financial resources.

12. Comply with the Georgia DCH Administrative Policy and Procedures and DCH Grants-to Counties Policies for administration of funds.

IV. EQUIPMENT INVENTORY
Maintenance of a complete and accurate inventory of all equipment leased or purchased with WIC funds is an ongoing district responsibility. Updates to the Georgia WIC Inventory Database are required whenever new non-ADP equipment over $1,000 or new (any dollar amount) ADP equipment has been acquired. Equipment that is transferred, surplused, destroyed or reported stolen or missing also requires an immediate update to the database.
Updating the database falls into one of the two categories, acquisition and status change. It is understood that districts will provide the State Office with

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GA WIC 2010 PROCEDURES MANUAL

Administrative

appropriate and immediate notification of their equipment acquisitions and status changes as follows:

A. Acquisition

Acquisition of a new item requires the districts to complete a new record in the database and send a copy of the newly written database, electronically to the state office. The State Office will then overwrite (save) the appropriate copy in its master file.

B. Status Change

Change in the status of an item requires the districts to complete the Equipment Status Changes Form/Transfer Form & Invoice (See Attachment AD-2) with appropriate fields marked to reflect that change. Forward the completed form to the WIC Program by mail and approved by the proper authority. Changes in the master file are then made by the WIC Personnel and a copy of the new district portion of the database is electronically mailed back to the district. The district must then overwrite (save) that copy in their database directory. This will ensure that both the district portion and the state master file are in agreement and fully updated. Instructions for each status change are listed below:
1. Surplus Equipment

Surplus Equipment according to DCH Real and Personal Property Management Manual Regulations.

2. Equipment Without Value

Equipment that is no longer valuable and/or usable and is scheduled for destruction must be noted on Attachment AD-2. Also attach a Destruction of Surplus Property Affidavit, which must be signed by the appropriate state authority and returned to the district prior to their taking any action.

3. Missing Equipment and Stolen Equipment

Districts are to complete Attachment AD-2 attach a brief explanation of the circumstances leading to equipment disappearance and attach a police report. Should equipment be

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recovered, complete Attachment AD-2; attach an explanation for equipment reappearance. Forward all forms to the WIC Program.

V. RETROACTIVE BENEFITS AND REIMBURSEMENTS
A. Revenue
Any revenue generated as a result of administering the WIC Program is considered as governmental and/or program income and must be used to further program objectives in accordance with the Code of Federal Regulations (CFR), Title 7, and Section 3016.25.
B. Misuse of Funds
Any vendor, local agency or state agency and/or individual(s) that embezzle willfully misapply, steal or obtain by fraud any funds, assets or property provided (whether received directly or indirectly from USDA) valued at $100.00 or more will have to pay a penalty of $25,000. SFP Regional letter, #250-04, March 8, 2004.
VI. LOCAL AGENCY COLLECTIONS
Local agency collections are funds recovered through the collection of local agency claims. Under 7 CFR 246.19(b), the State agency is responsible for monitoring local agency operations including financial management systems. If any food or NSA funds provided to a local agency was misused, diverted from program purposes, or lost as a result of thefts, embezzlements, or unexplained causes, the State agency should assess a claim against the local agency, as well as require the local agency to submit a corrective action plan.

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SECTION TWO STATEWIDE COST ALLOCATION PLAN
I. INTRODUCTION TO WIC STATEWIDE COST ALLOCATION PLAN
PURPOSE
This plan describes methods for assigning costs to a State or local agency's WIC Program grant or sub-grant. State and local agencies shall use this guide in assigning costs to WIC, except where other documents, such as an Advance Planning Document (APD), statewide Cost Allocation plan, indirect cost rate agreement, etc. prescribes other methods.
AUTHORITY
The WIC authorizing statute at 42 U.S.C. 17(h)(1)(A) provides that FNS shall allocate Federal WIC funds to States each fiscal year "for costs incurred by State and local agencies for nutrition services and administration for such year." The Federal cost principles stated in OMB Circular A-87 (Cost Principles for State, Local, and Indian Tribal Governments), OMB Circular A-122 (Cost Principles for Nonprofit Organizations), and 31 CFR Part 74, Appendix E (Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts With Hospitals) provide general rules for use by the respective types of organizations to which they apply in charging costs to Federal programs for reimbursement by Federal awarding agencies. Program-specific allowable cost rules are found at 7 CFR 246.14 and in written guidance issued by Food and Nutrition Services. This plan implements these authoritative documents with respect to the WIC Program.
BACKGROUND
The Congress created the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to serve as an adjunct to good health care for lowincome women, infants, and children. Its primary mission is to provide nutritious supplemental foods and nutrition education for such persons during critical times of growth and development.
As important as nutrition is to overall health and well-being, the Congress also recognized that nutritional services without other primary health care and related social services are simply half-measures. Therefore, WIC is also tasked with operating as a front-line health screening and risk assessment program and serving as a linkage or gateway to health care and social services. WIC accomplishes this by performing an aggressive information and referral function.

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Many costs incurred by State or local agencies are directly attributable to the WIC Program; these are known as direct costs. However, the delivery of WIC benefits has great potential to overlap the health service parameters of a number of other State and Federal public health and public assistance programs. Examples of such programs include those funded under Title V of the Maternal and Child Health Block Grant, Community and Migrant Health Centers, Medicaid (especially its Early and Periodic Screening, Diagnostic and Treatment (EPSDT) component),
Immunization, Head Start, and the WIC Farmers' Market Nutrition Program. The same costs that benefit WIC often benefit these and other programs as well. Such shared costs must be assigned to programs through a process of allocation.
This is particularly true in cases where State and local agencies have integrated the delivery of program services in order to make them available to clients in a "one-stop shopping" mode. While this operating method minimizes duplication of effort between programs, it results in different programs sharing many costs. The trend toward the integration of health service delivery magnifies the need for cost allocation systems sophisticated enough to assign WIC its fair share of costs, but not so complex as to create administrative burdens that discourage "one- stop shopping."
PUBLIC HEALTH GRANT-IN-AID PROGRAM
Georgia's County Public Health Departments are the service-delivery arm of the Division of Public Health. While they are independent legal entities, through the means of a contract, they work with the Division to provide public health services to the citizens of the state.
WIC funds are allocated to the Lead County Health Department as part of the Department's Grant-in-Aid Program and, as such, are recorded into the department's (Uniform Accounting System) UAS computer system. UAS then interfaces with the department's financial records. This allows for the reimbursement to the Lead County Health for expenditures and for the preparation of financial reports.
COST DISTRIBUTION
Programs that are part of Public Health's Grant-in-Aid to Counties (GIA) may have some of their costs direct charged. All of the costs that are direct should be directly charged to a program. The remainder should be allocated.

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Costs are collected monthly by the UAS and updated to PeopleSoft. When the update to PeopleSoft occurs, the direct charged programs are posted to their funding sources and the UAS cost pool amounts are recorded, the costs from the Grant-in-Aid cost pool are allocated to the funding programs.
COMPOSITION OF COST
Direct Costs are those that can be identified specifically with a particular cost objective. All expenditures are direct cost including all employees 100% paid by WIC and non WIC paid employees who occasionally perform WIC services.

II. BASIC COST PRINCIPLES/WIC ALLOWABLE COSTS
GENERAL REQUIREMENTS
The basic guidelines for identifying costs which may be charged to a Federal grant are found in OMB Circular A-87 for State agencies and governmental local agencies, and in A-122 for non-governmental, nonprofit local agencies. These circulars are implemented by departmental regulations at 7 CFR Part 3016.22(b) and 3019.27, respectively. In addition, section 3019.27 establishes 45 CFR Part 74, Appendix E as guidance for USDA programs operating in hospitals. To be deemed an allowable charge to a Federal grant under these guidelines, a cost must:
A. Be reasonable and necessary to carry out the program.
B. Be treated consistently. This means that costs incurred for the same purpose in like circumstances must be consistently charged to a Federal grant as either direct costs or indirect costs.
C. Be consistent with and allowable under Federal, State and local laws, regulations and policies.
D. Be determined in accordance with generally accepted accounting principles (except where the applicable Federal cost principles expressly provide otherwise) and adequately documented.
E. Be net of applicable credits.
F. Be charged to the correct accounting period.

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G. Not be charged to more than one Federal grant or used to meet a matching or cost sharing requirement for more than one Federal grant, either in the current or a prior accounting period.

H. Be allocable. A cost is allocable to the Federal grant only to the extent that it benefits the grant's objective.

I. Costs must be allocated equitably in terms of the benefit derived. To accomplish this requirement, the relative benefit must be approximated through the use of a reasonable method.
A cost is considered reasonable, if in nature and amount, it does not exceed what a prudent person would spend for a like item or activity to achieve the program's objectives. Costs incurred to carry out essential WIC Program functions, and which cannot be avoided without adversely impacting WIC Program operations, will be considered necessary. Costs determined to be reasonable and necessary to meet WIC Program objectives are allowable charges to the Federal WIC grant, provided these costs meet the other requirements for allow ability. Since the WIC grant is limited in amount, the priority of the expenditure in relation to other demands on available resources must also be considered.
Activities considered necessary to achieve WIC Program objectives are discussed in this chapter. They may be performed solely for the benefit of meeting WIC Program objectives, or to meet objectives of both WIC and non-WIC Programs. Further, these activities may be performed by WIC-only or multiple-program employees. The costs of the activities are allocable to the WIC Program grant to the extent that the activities are performed to benefit the WIC Program.
COMPONENTS OF FEDERAL WIC GRANT
The WIC Program's authorizing statute, the Child Nutrition Act of 1966, as amended, provides that a State agency's Federal WIC grant will consist of two components: one for the cost of supplemental food benefits and one for the costs of nutrition services and administration (NSA). Costs necessary to fulfill Program objectives (e.g., costs to provide WIC Program participants with supplemental foods, nutrition education, breastfeeding promotion and support and referral to related health services) are allowable charges to the applicable component of the WIC grant.

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NUTRITION SERVICE ADMINISTRATION (NSA) COSTS - GENERAL
A state or local agency must perform the following functions in order to meet WIC Program objectives: nutrition education, breastfeeding promotion and support, participant certification and caseload management, food delivery, screenings for and referrals to other social and medical service providers and general programs management. Therefore, the costs associated with these functions are allowable charges to the NSA component of the Federal WIC grant; provided these costs meet the other requirements for allow ability.
FOOD COST
The WIC food delivery system is managed by the Georgia WIC Program.
NSA COSTS FOR CLINIC ACTIVITIES
The following activities performed in WIC clinics are considered necessary to meet WIC Program objectives. Therefore, provided all other requirements for allow ability are satisfied, the direct and indirect costs associated with performing these activities are allowable charges to the WIC NSA grant.
A. Participant Certification/Case Management

1. Data Collection/Risk Assessment for Eligibility Determination

i) obtain application data/assess for eligibility name/income/residency, etc.
ii) anthropometric screening (heights, weights) and blood work (hematocrits or hemoglobin).
iii) obtain and/or score diet recall.
iv) screening for other medical conditions which affect the participant's nutritional status and needs substance abuse, food allergies, diabetes, etc. (no laboratory analysis).
2. Case Management

i) nutrition care plan development.

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ii) Maintenance of participant manual/automated charts/records.
iii) appointment scheduling/reminders and reviewing certification/recertification information needed with applicant/ participant.
iv) participation in public health needs assessment/ surveillance activities related broadly to maternal and child health as long as WIC has access to information gathered.

B. Nutrition Education

1. Preparing/scheduling/providing group or individual nutrition education.

2. Preparing nutrition education materials.

3. High risk nutrition counseling.

C. Breastfeeding Promotion and Support

1. Preparing/scheduling/providing group or individual breastfeeding promotion and support.

2. Preparing breastfeeding promotion and support materials.

D. Food Delivery 1. Development of/assigning WIC food packages.
2. Issuing food instruments/accounting for food instrument issuances.
E. Health Care Referrals
The costs of some screening (excluding laboratory tests), referrals for other medical/social services such as immunizations, prenatal and prenatal care, well child care and/or family planning, and follow-up on

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participants referred for such services, may be charged to the WIC grant. However, the cost of the services performed by the other health care/social service provider to which the participant has been referred shall not be charged to the WIC grant.
A hematological test for anemia such as a hemoglobin, hematocrit, or free erythrocyte protoporphyrin test is the only laboratory test required to determine a person's eligibility for WIC. As such, the cost of a hematological test for anemia is the only laboratory cost that may be charged to the WIC grant. Laboratory tests to screen for other health conditions including, but not limited to, pregnancy, lead and diabetes are not allowable charges to the WIC grant. When WIC operates in a clinic which requires complete blood samples for more complex blood tests, WIC will only pay an agreed upon amount that approximates the cost that WIC would have incurred if it had conducted its own blood tests (hemoglobin, hematocrit or free erythrocyte protoporphyrin tests) for WIC eligibility.
NSA COSTS FOR PROGRAM MANAGEMENT ACTIVITIES
The following program management activities are considered necessary to meet WIC Program objectives; and therefore, the costs associated with conducting these activities are allowable charges to the WIC Nutrition Service Administration grant component.

A. Maintaining accounting records.

B. Audits.

C. Budgeting.

E. Food instrument reconciliation, monitoring and payment.

F. Vendor Monitoring.

G. Outreach.

UNALLOWABLE COSTS
Under no circumstances may the Federal WIC grant be charged in full or in part for the costs of services which are demonstrably outside the scope of the WIC

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Program's authorizing statute. For example, the WIC grant may be charged to screen WIC participants for immunizations and refer and follow-up on WIC participant immunizations, but WIC may not be charged for the cost to administer the shot, the vaccine or vaccine-related equipment. Further, costs which are specifically disallowed by applicable Federal cost principles may not be charged to the WIC grant.
COST-RELATED COMPLIANCE REQUIREMENTS
The WIC Program's authorizing statute and program regulations at 7 CFR, section 246.14(c) require a State to incur a stated level of cost for each of two functions, nutrition education, breastfeeding promotion and support.
A stated fringe benefit rate must be applied to the WIC Program direct salaries.
While WIC is designed to be 100 percent federally funded, its authorizing statute and regulations provide for Food and Nutrition Services to grant prior approval for a State to meet part of its nutrition education and/or breastfeeding promotion and support requirement(s) with resources other than its Federal WIC grant. A State exercising this option must document the application of such other resources to the costs of these functions. Such documentation must meet the same standards as documentation of costs supported by Federal WIC grant funds.

III. METHOD FOR CHARGING THE COST OF WAGES AND SALARIES
STRUCTURE OF COST DATA
A State or local agency must record data on WIC employees' and non WIC paid employees that occasional perform WIC services. Time and effort of employees engaged in WIC cost objectives must provide documentation supporting the distribution of time and effort. The recording of employees compensated time to WIC must be supported by a Personnel Activity Reports (PAR). This documentation should reflect a real time recording of the actual activity performed, including who did it, whom it was done to, the date it was done, what was done, how long it took and how much it cost. (A-87; Attachment B, paragraph 11.h (1) - (2); A-122, Attachment B, paragraph 7.m (1); 45 CFR Part 74, Appendix E, paragraph 1X, B, 7, C).
All local agencies that perform WIC service delivery must use the Personnel Activity Report. All WIC paid and Non-WIC paid employees that occasionally perform WIC service must record the required data on the PAR.

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PERSONNEL ACTIVITY REPORT

Principles
1. Data Gathering Process Except where special rules apply, employees must record their time on a PAR which:

Shows employee ID.

Shows the date of activity.

Shows participant's WIC ID number (only if eligible for WIC).

Shows individual or group.

Shows applicant ineligible.

Shows actual time performing services in an appropriate cost objective.

METHODOLOGY
Personal Activity Report System (PARs)
PARs is a time keeping system that allows you to post time for WIC services provided. This document will illustrate a step by step method of time spent for activity in the WIC Program.
Who will document their time? All 100% WIC Paid and Non-WIC Paid Staff.

Locate the PARs icon

then double click to open the application.

Enter your Employee ID - numeric field that must be at least 6 characters in length.

Enter Password - Passwords must be at least 4 characters in length. Input can be alpha or numeric or a combination of both.

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The next screen to appear will prompt you to save your Employee ID and password. Verification will be made against CSC's server to ensure the Employee ID is valid. NOTE: This window will only appear the first time you log into the application.
The Clinic field will display the Clinic you are approved to provide services for. If you service multiple clinics, click the drop down arrow next to clinic and select the proper Clinic number that you will be posting time for.
If you have forgotten your password, click on the "Forget Your Password?" located at the bottom of the PARs Login window. The below window will appear. You will need to contact the Help Desk at (800)665-1516 for an access code. Please provide the Help Desk with your Employee ID and Full Name.
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Once you have entered the Access Code, enter a new password, confirm password. You will then receive the following message:
Click OK. The Login screen appears, enter your new password and choose the clinic where services are being provided.
Click Log In. Once the application has been launched the following screen displays:
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You will notice an entry already in the Grid the very first time you log into the application. This record will be overwritten the first time you enter an actual time entry and press Save. This record is only used to force the display of the grid after the application has been installed. Clinic Displays the clinic location that was chosen from the Login.
Date - The Date defaults to today's date, but can be modified if posting time for a previous date up to 3 actual business days. If entering a date older than 3 business days, when save is pressed the following message displays. You will need to correct the date field before proceeding.
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WIC ID Enter a valid WIC ID for the WIC client in which services have been provided.
Time You can select the amount of time spent providing the service by clicking the up/down arrows to the right of the field. The time may also be manually entered.
NOTE: Time must be entered in hour increments. i.e.; 15 minutes should be posted as .25
Activity Choose from the list the type of Service provided. There are six options to choose from:
a) Client Services b) Individual Nutrition Ed. c) Group Nutrition Ed. d) Breast Feeding Ed. e) Non-Client WIC Services f) Client Ineligible for Service
Once the information has been input, click the Save button. The information will immediately be sent to CSC via WebService. You will need to ensure the computer has internet access.
When the Group Nutrition Ed. Option is selected, the screen will allow additional entry of WIC ID's for WIC Clients who participated in the class. Up to 10 ID's may be entered.
If more than 10 clients participated only log partial time to the first group, then begin another Group Nutrition Ed entry, adding the remaining WIC ID's and the remainder of the time. i.e.; If 12 clients attended the class that lasted 1 hour, enter the first 10 WIC ID's with a time of .50 then the remainder of 2 WIC ID's of .50.
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Below is an example of the screen that will appear when the Group Nutrition Ed. option is selected:

Once the information has been input, click the Save button. The information will immediately be sent to CSC via WebService. You will need to ensure the computer has internet access. A successful transmission will display as Green in the grid.
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If a record displays in Blue in the Grid once Save has been pressed, this means that the record has not yet been sent to CSC. You should check and verify if you are able to access the internet, if not, the record will be sent once connection is restored. If you find you are able to access the internet successfully, please contact the CSC help desk at (800)665-1516 for assistance. The following example displays a record that has not been successfully transmitted.
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An unsuccessful transmission displays in Red.
At this time the record displayed as red will need to be edited to correct the problem. In the Entry Status box at the bottom of the window displays the field that needs correction. NOTE: If the record returns as Green nothing will appear in the Entry Status Box.
Select the record in the Grid by clicking in the gray box to the left of the ID#, this will place an arrow next to the record, then press Edit. This places the information at the top of the time entry window where corrections can be made. Editing cannot be done within the Grid. Once the corrections have been made, press Save to transmit the information.
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DEFINITIONS OF FUNCTIONS
At a minimum, reportable functions on PAR must include six (6) functions identified
1. Client Services
Participant/Applicant request WIC services. Demographic information entered into system. Other WIC participant services. Lab Work Voucher issuance

2. Nutrition Education Costs (007) Federal regulations require that each WIC State agency spend one-sixth of its NSA Grant for Nutrition Education.

3. Group Nutrition Education Two or more clients.

4. Breastfeeding Costs (009)
A local agency is required to spend WIC breastfeeding funds for breastfeeding related costs and activities. The following breastfeeding costs are allowable:
Travel and training costs of staff associated with breastfeeding promotion and support activities.

Contracts for services of breastfeeding specialist.

Breastfeeding aids, such as breast pumps, breast shells, nursing supplements, nursing bras and nursing pads, which directly support the initiation and continuation of breastfeeding. A quarterly report listing breast pump expenditures including quantity and dollar amount should be submitted to the State WIC Financial Section by the 15th of the month following the end of the quarter.

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Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. Such items may include models to illustrate the use of various breastfeeding aids, dolls used to illustrate nursing, etc.

Development, procurement and distribution of materials, instructional curricula, etc., related to breastfeeding promotion and support.

Developing and updating the biennial Breastfeeding Promotion and Support Plan.

Payments for interpreters and the translation of breastfeeding materials.

The costs of agreements with other individuals or organizations, whether public or private, to provide breastfeeding training and direct service delivery to WIC participants.

5. Client Ineligible for WIC Services Activities where the Applicant is not eligible for WIC.

6. Non Client WIC Services
Activities that are WIC related such as clerical, promotional and general WIC work that has no WIC client involvement.
REQUIREMENTS
1. Employee ID number/by Clinic (provided by District) and must be updated within three (3) days upon employment status change.

2. Hourly pay rate (provided by District) and must be updated within three (30 days of status change.

3. WIC ID number of each participant that receives WIC services.

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NUTRITION SERVICES AND ADMINISTRATION COST CATEGORIES

A. WIC Cost Pool (301)

All Salaries of 100% WIC paid employees and non WIC employees that occasionally perform WIC's work.

B. WIC Revenue Account (7040)

Counties that receive WIC funds from Lead County to reimburse the salary of non-WIC paid employees that occasionally perform WIC work.

C. WIC Direct Costs (643)

Allowable administrative and operational costs are those costs necessary to fulfill program objectives.
100% WIC expenses that do not qualify under Nutrition Education or Breastfeeding activities such as office supplies, WIC forms, rent, telecommunication, maintenance, postage, travel, contracts promotion items and outreach activities specific to WIC.

All pre-approved equipment and computer purchases.

Allowable Central Cost Allocation Expenses.

All other allowable expenses.

IV. METHOD FOR CHARGING SALARY AND NON-SALARY COSTS
OVERVIEW
The fundamental principle for assigning non-salary costs to cost objectives is the same as for salary costs: a State or local agency assigns a cost item incurred solely for a single cost objective to that cost objective; a cost incurred for multiple cost objectives must be distributed to such cost objectives such that each bears a portion of the cost commensurate with the benefit received from it. When allocating shared non-salary costs to several different programs or other cost objectives, it is important to group pools of costs to be allocated and select bases

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for allocating such costs in a manner which will produce equitable and reasonable charges to each cost objective.
Most government units provide certain services, such as motor pools, computer centers, purchasing, accounting, etc., to operating agencies on a centralized basis. Since federally-supported awards are performed within the individual operating agencies, there needs to be a process whereby these central service costs can be identified and assigned to benefitted activities on a reasonable and consistent basis. The central service cost allocation plan provides that process. All cost and other data used to distribute the costs included in the plan should be supported by formal accounting and other records that will support the propriety of the costs assigned to Federal awards.
Guidelines and illustrations of central service cost allocation plans are provided in a brochure published by the Department of Health and Human Services entitled "A Guide for State and Local Government Agencies: Cost Principles and Procedures for Establishing Cost Allocation Plans and Indirect Cost Rates for Grants and Contracts for the Federal Government." A copy of this brochure may be obtained from the Superintendent of Documents, U.S. Government Printing Office.
A. Definitions
1. "Billed central services" means central services that are billed to benefitted agencies and/or programs on an individual fee-forservice or similar basis. Typical examples of billed central services include computer services, transportation services, insurance, and fringe benefits.

2. "Allocated central services" means central services that benefit operating agencies but are not billed to the agencies on a fee-forservice or similar basis. These costs are allocated to benefitted agencies on some reasonable basis. Examples of such services might include general accounting, personnel administration, purchasing, etc.

3. "Agency or operating agency" means an organizational unit or subdivision within a governmental unit that is responsible for the performance or administration of awards or activities of the governmental unit.

B. Scope of the Central Service Cost Allocation Plans

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The central service cost allocation plan will include all central services costs that will be claimed (either as a billed or an allocated cost) under Federal awards and will be documented as described in Circular 87, Section E. Costs of central services omitted from the plan will not be reimbursed.
LEAD COUNTY COST ALLOCATION PLAN
All Lead Counties claiming central service costs must develop a plan in accordance with the requirements described in Circular 87 and maintain the plan and related supporting documentation for audit. Since Lead Counties receive funds as a sub-recipient, the State will be responsible for negotiating indirect cost rates and/or monitoring the sub-recipient's plan. The Health District must submit a Central Cost Allocation to the Department for approval.
CENTRAL COST ALLOCATION PLAN FOR COUNTIES
The Lead County may allow the counties within its District to charge a Central Cost Allocation to their WIC funding. A Central Cost Allocation are those costs that are common to all Programs, such as gas, electric, water, maintenance, security expenses and other approved cost. All Programs must be charged based on an equitable methodology, such as occupied space or number of employees. For a County to charge a Central Cost Allocation, the County must submit a Central Cost Allocation Plan for review and approval to the Lead County. The Lead County must provide at least annually a review, approval, monitoring and oversight of the Plan. A copy of the County approved Plan must be maintained on sight at the Lead County office and available upon the request of auditors. A copy of the Plan must be provided to the State WIC Office.
BASES FOR DISTRIBUTING SHARED SERVICES
The following table lists suggested bases for distributing shared costs. The suggested bases are not mandatory for use. Any base which produces an equitable distribution of cost may be used. These bases may be used to distribute and directly charge non-salary costs not covered in an indirect cost agreement approved by the cognizant agency or to negotiate an indirect cost agreement with the cognizant agency.

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TYPE OF SERVICE

SUGGESTED BASES FOR ALLOCATION

Accounting Budgeting
Buildings lease management Data processing Disbursing service Employees retirement system administration Insurance management service Legal services Mail and messenger service
Motor pool costs including automotive management Office machines and equipment maintenance Office space use and related costs (heat, light, janitor services, etc.) Organization and management services Payroll services Personnel administration Printing and reproduction Procurement service Local telephone Health services Fidelity bonding program

Number of transactions processed. Direct hours of identifiable services of employees of central budget. Number of leases. System usage. Number of checks or warrants issued. Number of employees contributing.
Direct hours.
Direct hours. Number of documents handled or employees served. Miles driven and/or days used.
Direct hours.
Square foot of space occupied.
Direct hours.
Number of employees. Number of employees. Direct hours, job basis, pages printed, etc. Number of transactions processed. Number of telephone instruments. Number of employees. Employees subject to bond or penalty amounts.

INEQUITABLE METHODS OF COST ALLOCATION

If a cost allocation method produces an inequitable distribution of costs, this may result in questioned or disallowed costs during a subsequent audit. The incidence of inequitable allocation of non-salary costs to the WIC Program occurs much less frequently than the incidence of inequitable allocation of salary costs

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to the WIC Program. However, the following are just a few examples that have been documented in recent audit reports:

A. Facility expenses (building use, janitorial services, utilities, etc.) had been allocated on the basis of the number of employees rather than the square footage occupied. This resulted in a disproportionate share of the total cost allocated to WIC. A tour of the facility revealed that the peremployee space was not consistent among programs. Typically, other programs that were co-located with WIC had much more space per employee than did the WIC Program. Therefore, square footage occupied generally provides a more reasonable and equitable distribution of this cost.

B. Allocating professional liability insurance coverage to WIC based on the number of patient visits without regard to the risk involved in each visit produced inequitable charges to WIC. When contacted, the insurance company stated that WIC had been included in the insurance coverage at no additional charge due to its low risk. An equitable method for allocating malpractice insurance to WIC would consider the amount of the professional's time spent on WIC Program operations and the relatively low risk of the certification process.

C. Supplies (a pool of costs) allocated to WIC included supplies not used by nor allowable for the WIC Program, such as popcorn and toothbrushes for a health fair and flowers for an employee on sick leave. When allocating a pool of costs, the pool should consist only of allowable costs.
EXPENSING EQUIPMENT PURCHASES
The preferred method of recovering the cost of a capital asset, such as equipment, is to claim depreciation expense or use allowance under A-87, Attachment B, paragraph 15 or A-122, Attachment B, paragraph 11, as applicable. However, a State or local agency may seek prior approval to charge the entire acquisition cost of the equipment to the Federal grant or subgrant for the fiscal year in which the purchase is made (that is, "expense" it). If more than a negligible portion of the "expensed" equipment's use is expected to benefit programs other than WIC, then WIC cannot bear the entire acquisition cost. Rather, the State or local agency must allocate the acquisition cost among programs on the basis of their anticipated respective benefit from the equipment's use.

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SECTION THREE - PROGRAM ADMINISTRATION
I. RETENTION OF RECORDS

A. Definition of Records

Federal Regulations state: "Records shall include, but not be limited to, information pertaining to financial operations, food delivery systems, food instrument issuance and inventory, certification, nutrition education, civil rights and fair hearing procedures" [7 CFR 246.25(a)(1)].
State policy memos from the previous year may be destroyed once the new Procedures Manual has been received, unless otherwise instructed. For example, FFY `06 Policy Memos may be destroyed once the FFY `07 Procedures Manual has been received.

B. Records and Reports - Accessibility of Records

Food Nutrition Services (FNS) may require the State or local agencies to supply medical data and other information collected under the program in a form that does not identify particular individuals, yet enable the State agencies to evaluate the effect of food intervention upon low-income individuals determined to be at nutritional risk.

C. Retention Schedule

1. The following documents must be retained for three (3) years plus current Federal Fiscal Year:
(1) WIC Assessment/Certification Forms (2) Diet Histories (3) Growth Charts/Weight Gain Grids (4) VOC Card Inventories (5) Medical Records (6) WIC Termination/Ineligibility/Waiting List Forms (7) Vendor Monitoring Reports (8) Computer Generated Voucher Registers/Voucher Printing On
Demand (VPOD) Receipts (9) Manual Voucher Inventory Records (10) Budgets and Expenditure Reports (11) Contracts (12) Indirect Cost Plan (13) Shared Costs Documentation

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(14) Fair hearing and civil rights complaints and all related documentation
(15) Federal, State, District, County Audit reports (16) Copies of manual vouchers (17) Vouchers Activity Report (18) Dual participation Reports* (19) Cumulative unmatched Redemptions (20) Part 1* (not matched to issuance record) (21) Cumulative Unmatched Redemptions (22) Part 2* (not matched to a valid certification record) (23) Batch Control Report (24) Batch Control Form and Module (25) Critical Error Report (26) Canceled food instruments (27) Lost/Stolen/Destroyed/Voided Voucher Report (28) Separation of Duty Form/District Office (29) Request for WIC Services Log
2. The following documents must be kept for two (2) years: (1) Voter Registration Documentation (2) Master List
3. The following documents must be retained for one (1) year plus the current year: (1) Waiting List (2) Voucher Packing List/VPOD Confirmation Notice (3) TAD's
*The original copy of these reports with their manual reconciliation must be sent to the Georgia WIC Program prior to being destroyed. The Georgia WIC Program will maintain these reports for four (4) years.

D. Prior Approval/Duplication of WIC Records

Local Agencies must request prior approval for the reformatting or modification of office WIC forms (i.e, pamphlets, flyers...). Please forward revised, reformatted or modified forms to the WIC Program or Office of Nutrition for prior approval before distribution. If the local agency duplicates an official WIC form, the local agency is responsible for ensuring that the form contains the exact information as its original.

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The following documents are available through the Georgia WIC Information System (GWIS). GWIS documents are accessible via the web for a period of three (3) years plus the current Federal Fiscal Year: a. Monthly Reconciliation - Enrollment Cycle
1. Alphabetic Master File Listing 2. Critical Error Report 3. Enrollee Income by Household Size 4. Grady Hospital Enrollee Distribution 5. Medicaid-Enrollee Income by Household Size 6. Medicaid-Percentage of Poverty Income by Type and Age
Categories 7. Medicaid-Priority Counts by Percentage by Poverty
Income Level 8. Numeric Master File Listing 9. Percentage of Poverty Level Income Level by Type and
Age Categories 10. Priority Counts by Percentage of Poverty Income Level 11. Trimester Analysis Report 12. Unduplicated Participation Report, State Fiscal Year 13. Unduplicated Participation Report, Federal Fiscal Year 14. Waiting List Report 15. WIC Status (Type) by Reason Certified
b. Monthly Reconciliation
1. Bank Exception Report 2. Bank Listing 3. Closeout Reconciliation Report 4. Cumulative Unmatched Redemptions Over 30 Days-
Based on CUR-Part 1 5. Cumulative Unmatched Redemption Over 30 Days-Based
on CUR-Part 2 6. District Unit/County Compliance Summary
(Concentrated Powder Ready To Feed). 7. Dual Participation Report-Part 1 8. Ethnic Enrollment and Participation by Priority (Issue 30
Day) and Closeout 9. Ethnic Participation Summary 10. Financial and Program Status 11. Food Cost Allocation (Projection) 12. Food Package Create Report 13. Food Package Expenditures Report

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14. Infant Formula Rebate Report Concentrated, Powder, Ready To Feed
15. Infant Rebate County Summary 16. Infant Rebate District Unit Summary 17. Migrant Participation Summary 18. Migrant Enrollment and Participation by Priority (Issue 30
Day) and Closeout 19. Monthly Report of Food Expenditures Summary (Issue 30
Day) and Closeout 20. Monthly Report of Food Expenditures by Vouchers Code
(Issue 30-Day Closeout 21. Participant Totals 22. Participation Summary by District/Unit 23. Previously Unmatched Redemptions, Which Were
Matched 24. Unmatched Redemption's Report 25. EVOC Card Information
c. Monthly Reconciliation - Vendor Cycle
1. Cumulative Vendor Totals 2. Detailed Flagged Voucher Listing 3. Flagged Voucher by Vendor per Peer Average 4. Maximum Amount Input Update 5. Statistics File for Vouchers 6. Vendor Exception Report 7. Vendor Listing 8. Vendor Update Listing 9. Vendor Voucher Deviation Report 10. Voucher Redemption Fluctuation Report 11. Voucher Variation Report 12. Voucher by Day Cashed 13. Vouchers Cashed by Clinics 14. Financial Records

II. WIC ACRONYM AND LOGO
A. Authority
The acronym "WIC" was registered with the U.S. Patent and Trademark Office January 1, 1991. The WIC logo, a stylized representation of a woman holding an infant in her arms and a child by the hand, was registered April 16, 1991. Regulations authorizing the use of the WIC
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acronym and logo are provided in 42 U.S.C. 1786, 15 U.S.C. 1051 et seq., and 7 CFR Part 246.
It is an on-going policy to discourage the industrial use of the WIC acronym and logo on products to avoid certain difficulties that may be encountered.

B. Official Use

The WIC logo and acronym is to be use for official use only. FNS reserved

the right to approve and use of the logo and acronym. WIC program may

use the logo or acronym on the items below:

Brochures

Leaflets

Bulletins

Letters

Business Cards (for employees) Manuals

Cups

Newspapers

Directories

Posters

Food Instruments

Radio and T.V. Announcements

Forms (i.e. Cert. forms)

Reports

Guides

Studies

Immunizations Initiatives

T-Shirts

C. Special Use

Profit and Non-Profit Organizations -The WIC logo and acronym cannot be used by for profit organizations. These organizations are not permitted to display the acronym or logo in total or in part, including close facsimiles, on any product or materials. Non-profit organizations may be permitted to use the acronym and/or the logo for non-commercial educational purposes when such use is essential to public service and will contribute to public information and education concerning the WIC Program. Non-profit organizations are those organizations that are exempt from taxation under Federal law, including charitable and educational organizations. Nonprofit organizations within the jurisdiction of the state of Georgia shall submit a request for use of the WIC acronym or logo to the Georgia WIC Program in writing. The written request must include a copy/sample of the way in which the acronym or logo will be used. The Georgia WIC Program must respond in writing as to whether such use is authorized.

D. WIC Food Vendors

At the discretion of the Georgia WIC Program, a vendor may be

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authorized to use the acronym and/or logo for the following purposes: a. To identify the retailer as an authorized WIC food vendor.
b. To identify authorized WIC foods by attaching channel strips or shelf-talkers stating "WIC-approved" or "WIC-eligible" to grocery store shelves.

FNS reserves the right to approve any uses of the WIC acronym or logo. Any uses that are considered inappropriate shall be discontinued. Request for use of the WIC Acronym or Logo must be made in writing along with a copy/sample of the way it will be used. A written response will be issued as to whether such use is authorized.

E. Unauthorized Use

Any person, who uses the acronym "WIC" or the WIC logo in an unauthorized manner, including close facsimiles thereof, in total or in part, may be subject of injunction and the payment of damages. Any person who is aware of violations should provide the information to the Food and Nutrition Services (FNS) Office.

III. LOBBYING RESTRICTIONS
The State/local Agencies must not use federal funds for the lobbying of specific federal awards. Recipients of any federal grants, contracts, loans, or cooperative agreements are required to disclose expenditures made with their own funds for such purpose.

IV. CONFIDENTIALITY
The State/local agencies are required to restrict the disclosure of information obtained from any program applicant/participant (See Attachment AD-3).
WIC program information must not be released except in the following situations:
A. The WIC applicant/participant signs a release of information (See Attachment AD-4), when a request is made by the WIC participant herself or him.
B. The State or local agencies enter into a written agreement with an

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organization (i.e. immunization program). The Director of Public Health must sign this agreement. In the event an agreement is entered into with the organization and the Director of Public Health, a release of information would not need to be signed by the WIC applicant/ participant. Information shared with that agency however, is restricted (See Attachment AD-3). The Georgia WIC program has entered into agreements with the following organizations within the Department of Community Health, Division of Public Health:
Immunization Branch need agreements for USDA
Epidemiology Branch

Note: The WIC Certification Form and Rights and Obligations Form have been revised to meet these requirements.
C. For audits and examinations by the Comptroller General of the US, authorized by law.
D. For representation of the Department and Comptroller General of the United States to inspect, audit and copy. Any records or other documents resulting from the examination of such records that are publicly released may not include confidential applicant or participant information.

E. Oral request from one WIC Program to another (in-state or out of state). Ensure that the request is official. If it is suspected the call is not official, call the agency back.

F. For receipt of a court order with an official Release of Information (see Attachment 13) from a Foster Care caseworker requesting information can only be released if: x The form is completed in its entirety
x A court order is attached
x Your District Attorney approves the content of the court order

Note: Information on the use of drugs and alcohol must not be shared.

V. E-MAIL AND FAXING CONFIDENTIAL INFORMATION
Districts that decide to fax or e-mail confidential information should incorporate confidentiality provision statement into your fax cover sheet information. If the

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information contained on the fax or in the e-mail is considered Private Health Information (PHI) then the (HIPAA) regulations governing the release of such information applies. The following represents an example of such a statement:
CONFIDENTIALITY NOTE
The information contained in this fax/e-mail message is intended only for the personal and confidential use of the designated recipients named above. This message may involve attorney-client communication and, as such is, privileged and confidential. If the reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and any review; dissemination, distribution or copying of this message is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us by mail. Our number is (404) 657-2900, and the fax number is (404) 657-2910.
THANK YOU.

VI. WIC VOLUNTEERS AND CONFIDENTIALITY
In order to prevent a breach of confidentiality, the Georgia WIC Program must exercise discretion in screening and selecting capable volunteers who will handle confidential information. It is therefore the responsibility of the local agency to ensure that volunteers who are given access to client information are well trained and knowledgeable of the restrictions in disclosure of patient information.
The following action steps must be taken in order to protect participant information:
A. Once volunteers are selected, specific confidentiality requirements governing the WIC Program must be covered in their orientation or training.
B. Follow-up training must be conducted periodically to remind volunteers, as well as paid staff, of the importance of maintaining the confidential nature of participant information.

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C. The selecting agency may have volunteers sign an agreement acknowledging restrictions on the disclosure of confidential information. By signing such a form, the volunteer would agree to keep information confidential or forfeit the volunteer assignment. Such an agreement would reinforce the importance of maintaining confidential participant information.

D. If a volunteer does not appear to be a good candidate for keeping information confidential, assign the volunteer to other activities in the program.

VII. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
By law, all WIC applicant/participant information while participating on the program must remain confidential except where disclosure is authorized by law (See 45 CFR Parts 160 and 164). This is a HIPAA requirement.
The privacy practices of WIC are in compliance with the HIPAA laws. State-toState transfers are allowable. A request for release of information is advised.

VIII. RETROACTIVE BENEFITS AND REIMBURSEMENTS
WIC regulations do not provide for retroactive benefits and reimbursement. The WIC Food Packages are designed to be consumed within a specified time period when participants are experiencing critical growth and development.
IX. MANDATORY NO-SMOKING POLICY
Public Law 103-111 prohibits the allocation of Administrative Funds to any clinic providing WIC services if that clinic allows smoking within the space used to perform program functions. In order to avoid administrative penalties, Local Health Department or WIC Clinics must display a No Smoking Sign. These signs must be visible somewhere in the clinic.
The prohibition against smoking applies only during the hours of actual WIC operations. In the event the clinics for voucher issuance are being held at a satellite clinic (i.e. church, public housing, clinic site, community health center only once or twice per week) then the no-smoking policy would only be in effect
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during WIC operation hours. If the health department is a no-smoking facility, and such signs are displayed throughout the health department, then there is no need to display a WIC specific no-smoking sign.

X. SUBPOENAS
A. Subpoenas
A subpoena is a request for information issued by a clerk of a court in response to a request by an attorney representing a party. A subpoena may be directed to an individual or an entity. In the event, the local agency receives a subpoena, please follow the instructions below. Also, please contact the Georgia WIC Program for legal advice.
B. Procedures for Responding to a Subpoena
1. State or local agencies, in consultation with their legal counsel, must make a determination based on the content of the subpoena and the requested information whether or not to comply with the subpoena and release the information as requested or to attempt to quash the subpoena. In making the determination, State or local agencies must determine whether the information is protected under 7 CFR 246.26(d) of the WIC regulations.
2. Decisions to release WIC information as requested by a subpoena or to attempt to quash a subpoena must be based on the requirements and restrictions set forth in 7 CFR 246.26(d) of the WIC regulations, any pertinent State laws, and FNS Instruction 800-1. Any conflicts identified between Federal and State requirements should be referred to the DCH Legal Services Office when appropriate.
3. If the court denies the motion to quash the subpoena and requires the WIC State or local agency to release the requested information, the State or local agency or legal counsel acting on its behalf shall attempt to: a. consider the appropriateness of an appeal of the decision b. ensure that the information produced is the minimum necessary to respond to the subpoena (i.e. provide related documents reflecting only the requested WIC information)

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c. attempt to negotiate the extent to which the WIC information actually produced becomes public information (i.e. reviewed in camera by the court, limited entry into the public record)
4. If the motion to quash the subpoena is denied by the court, we recommend that legal counsel acting on behalf of the State or local agency request the parties to reduce to writing the terms of the release of the subpoenaed information so that all parties are in accord as to the use of such information. Ideally, counsel should seek a warrant of attachment or similar court order. A warrant of attachment is a written order by the court based on State law, which orders a law enforcement officer to seize specific documents and deliver them to the court, essentially forcing the State or local agency to comply. In this way, there is a record that WIC State or local officials disregarded the Federal law protecting the confidentiality of WIC records only after having been compelled to do so by a court.

5. State/local agencies must advise legal counsel of any formal complaints that may result in litigation. Receipt of a subpoena or search warrant must also be reported to the WIC Program and legal counsel.

6. In some instances, a State or local agency may be required to release confidential information in response to a subpoena or search warrant. However, if the release of such information is made pursuant to and in keeping with WIC Program regulations, instruction, and policy, that release will not result in FNS or its agents taking adverse action against the State and local agency or any individuals acting on their behalf.

XI. SEARCH WARRANTS
In addition to the issuance of subpoenas, search warrants have been used by police investigators to obtain WIC applicant and participant information. State and local agencies must comply with search warrants. A search warrant differs from a subpoena in which a time frame is established to either comply with the subpoena or attempt to quash the request. Failure to fully comply with a search warrant at the time it is served could result in the incarceration of WIC State and local agency staff.

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XII. PROGRAM PARTICIPATION
The definition of a participant and enrollee is listed below:
Participant: Participants means pregnant women, breastfeeding women, postpartum women, infants and children who are receiving supplemental foods or food instruments under the program and the breastfed infants of participant breastfeeding women. A participant is a client who has been issued at least one voucher during the reporting month. The exclusively breastfed infant is issued a voucher message but no formula is issued.
Enrollee: A client who is active, during a valid certification period, but did not receive vouchers during the reporting month.

XIII. ESTABLISHING NEW CLINICS/CLINIC CHANGES
Effective immediately, new policies governing the opening of new clinic sites have been revised. All new clinics must have complete PreApproved - PreAward Compliance Review before the clinic can open.
Prior to creating a new clinic, the District Staff must complete and send the Policy Unit the following information below: 1. Demographics of the population to be served in order to evaluate
program access Racial makeup of the area you will be serving and who will be attending the clinic. A public health website that may be used to collect this information is http://oasis.state.ga.us/. 2. Data collected regarding covered employment including use of bilingual public-contact employees serving LEP (Limited English Speaking) beneficiaries of the programs Racial ethnic data of the employees that will be working at the new clinic. 3. Evaluation of the location of existing or proposed facilities connected with the program and whether access would be difficult or impossible because of locale Is there anyone who would be denied services due to the facility and racial makeup of the clinic. 4. Review of the composition of the planning or advisory board Racial makeup of the new facility. 5. Analysis of civil rights impact, if relocation of the clinic is involved Provide an analysis of the new location. This only applies when the clinic is relocating. 6. A written assurance by any program applicant or recipient that it will compile and maintain records required by the (FNS) Food Nutrition
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Service guidelines or other directives.
7. The manner in which services are or will be provided by the program in question, and related data necessary for determining whether any persons are or will be denied such services on the basis of prohibited discrimination.
8. A statement of notification from the program applicant or recipient to promptly notify (FNS) Food Nutrition Service of any lawsuit filed against the program applicant or recipient or sub recipient alleging discrimination on the basis of race, color, or national origin and that each recipient notify (FNS) Food Nutrition Service of any complaints filed against the recipient alleging such discrimination; and that each program applicant or recipient provide a brief description of any pending application to other Federal agencies for assistance, and of Federal assistance being provided at time of application or requested report .
9. A statement or description of previous civil rights reviews regarding the program applicant two years prior to applying as well as any information about the agency or organization performing the review and any periodic statements by the recipient regarding such reviews.

Note: Please note that a program applicant or recipient is the entity applying for program funding to serve WIC participants.
Once the analysis is completed and approved by the State, the Program Review Team will complete the New Clinic Evaluation Form (See Attachment AD-9).
Additionally, the Program Review Team will: Visit the potential new clinic Observe and determine compliance according to the WIC regulations
using Attachment AD-9. Mail a report indicating the following:
a. Approval by completing the New Site Permission Request Form (Attachment AD-7).
b. A list of changes needed prior to the opening of the clinic. c. Disapproval of the opening.

After the new clinic is approved, District Staff can complete the Request to Establish New Clinic/Clinic Change Form (Attachment AD-5). The State WIC Systems staff will verify processing the information and forward this form to the data processing contractor (Covansys) within five (5) days. The data processing contractor assigns a number for the new clinic. If the District selects its own number, the data processing contractor must verify and approve the number

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before it may be considered a valid number. The data processing contractor mails the new clinic the supplies necessary to start processing operations (i.e., TADs, vouchers, etc.).

Once your District receives an approved clinic number etc., you may begin to enroll WIC participants. The Georgia WIC Program will provide technical assistance, consultation and training to the Local Agency in the start up procedures of a new clinic, if needed.

A WIC clinic is a facility where WIC business is conducted. operates in the State must have its own number. This requirement applies to, but not limited to the following:
x All hospitals x DFAC clinics x Health Departments x 330 Community Health Organizations x Voucher Issuance x Health Centers x Migrant Clinics

Each clinic that

Failure to comply to list all of the clinics-sites locations in your District may result in a financial penalty for the District. These penalties may include refunding monies for vouchers issued from the date the clinics-sites opened. A Financial Penalty letter will be sent to your District if the Program Review staff finds clinics-sites either, a) operating and not on the WIC Clinic Listing or, b) does not have its unique clinic number.

XIV. CLINIC CLOSINGS
In the event a clinic is going to be closed temporarily due to an emergency, please notify the Policy Unit at the Georgia WIC Program as early as possible. This will enable the state/local staff to better serve the applicants/participants and clinic staff.
Closing of clinics causes participants/applicants hardship when they are not notified in writing or in advance.
If your district plans to close a WIC clinic permanently, please complete the Clinic Change form and mail it to the Policy Unit (Attachment AD-5).

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XV. DAMAGED FORMULA REPORT
The Formula Tracking Log (See Food Package Section) must be used to report free trade formula that is damaged on receipt.
When a formula shipment is sent damaged, complete the section of the form indicating the formula was discarded and the reason the formula was discarded and fax this form to the System Unit attention at the Georgia WIC Program. The Fax Number is (404) 657-2910.

XVI. REPORTING SYSTEMS PROBLEMS
Local WIC Agencies must immediately report any Covansys and/or front-end systems discrepancies to the Systems Information Section of the Georgia WIC Program. Systems discrepancies may include, but are not limited to, the following: duplicate vouchers, duplicate voucher numbers, inaccurate voucher numbers, vouchers without a number, or any action which causes an unmatched redemption. Fax the completed System Problem Report Form, (Attachment AD6) to the State WIC Program. In addition, the clinic should notify the District Nutrition Services Director and Management Information System's staff at the district office.

XVII. REQUEST FOR FINANCIAL AND/OR STATISTICAL DATA
Request for financial and/or statistical data or reports must be made in writing by completing the Data Request Form (See Attachment AD-8). Fax the Data Request Forms to the State WIC Program, (404) 657-2910, Attention Systems Information Section.

XVIII. IDENTIFICATION CARDS AND FOOD LIST ORDERS
The WIC ID Cards, Food List and Referral Form will be mailed to your district office from the contracted printer quarterly (Jan., April, July and Oct.) each year. If the amount received needs to be adjusted based on an increase or decrease in caseload, please contact the State WIC Program.

XIX. CLINIC/STAFF RATIO Clinic staff ratio is listed below for Administrative purposes:

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A. One (1) CPA per every 1,000 clients served. B. One (1) Administrative support staff per every 800 clients served. C. One (1) RD/LD per every 5,000 clients served.

XX. NUTRITION SERVICE DIRECTOR JOB DESCRIPTION
The Nutrition Services Director's position is an administrative position. Attached is a copy of the current job description, which describes the responsibilities (See Attachment AD-11).

XXI. COMPLIANCE REVIEWS
A. There are three (3) types of compliance reviews: x Pre-approved or Pre-Award x Post-Award or Routine x Special
B. Definitions
Pre-Approval or Pre-Award Review Reviews that must be conducted prior to the approval of a clinic opening. No Federal funds can be awarded to a state or local agency until pre-award compliance review is conducted and the applicant is determined to be in compliance with civil right rules. This review may be a desk or on site review. The results of the review must be in writing.
Prior to creating a new clinic site, the following must be reviewed for compliance: Demographics of the population to evaluate program access. Collect data regarding covered employment including use of
bilingual public-contact employees serving LEP beneficiaries of the programs. Look at the location of existing or proposed facilities connected with the program and whether access would be unnecessarily denied because of locale. Review the makeup of planning or advisory board. Conducts a Civil Right Impact analysis if relocation is involved.
Post Award or Routine Reviews Regular reviews or self-reviews where
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civil rights compliance is checked:
When conducting a post review or routine review, look for the number of discrimination complaints filed, information from grass roots and advocacy groups, individuals, state officials and unresolved findings from previous civil rights reviews.

Special Reviews Reviews conducted due to reported alleged noncompliance. Prior to this review, check patterns of complaints of discrimination through reviewing documentation at the state and district level.

XXII. MEDICAL NUTRITION THERAPY
Below are the policies regarding medical nutrition therapy and Medicaid. 1. 100% paid WIC employees (full time or part time) may not provide
Medical Nutrition therapy which is Medicaid reimbursed service. Any nurse, dietitian or other nutrition staff paid by WIC or any Federal Program may not bill Medicaid for medical nutrition therapy provided within or outside of the WIC clinics. This includes WIC certifications conducted as part of a home visit by non-WIC staff.
Example of inappropriate billing procedures: a. Non-WIC paid nurse making home visits and completing a WIC
Certification, and billing the WIC program.
b. Any WIC paid staff in the 301 Cost Pool must not participate in Medicaid reimbursement.

XXIII. REGISTERED AND/OR LICENSED DIETITIAN CREDENTIALING POLICY FOR DCH DIVISION OF PUBLIC HEALTH
It is the policy of the Department of Community Health Division of Public Health that those registered and or licensed professionals providing medical nutrition therapy in public health practice meet all standards and guidelines outlined in the credentialing expectations document. All licensed professionals participating in reimbursable services must be credentialed by June 1, 2006. The district nutrition service directors are responsible for monitoring the credentials and competence of county professional licensed dietitians in their districts.

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I. Professional Licensure a. Each professional dietitian shall, at all times maintain current license by the Georgia Board of Examiners of Licensed Dietitians b. Verification of licensure may be obtained via the internet (www.sos.state.ga.us).
II. Professional Registration a. Each professional with the designation of Registered Dietitian shall, at all times, maintain current registration by the Commission on Dietetic Registration. b. Verification of registration may be via internet (www.cdr.net)
III. Initial Practice a. Academic preparation i. Licensed Dietitian written documentation from an American Dietetic Association approved undergraduate dietetics program, which verifies required nutrition and science coursework and/or copy of current license. ii. Registered/Licensed Dietitian copy of current registration card from the Commission on Dietetic Registration of the American Dietetic Association and copy of current license issued by the Georgia Board of Examiners of Licensed Dietitians. iii. Provisionally Licensed Dietitian copy of verification statement from an American Dietetic Association Accredited dietetic internship program and copy of provisional license. b. Authority and Scope of Practice i. ADA Code of Ethics prior to the practice of medical ii. Nutrition therapy, all credentialed professionals will read and agree to abide by the Code of Ethics set forth by the American Dietetic Association. iii. DCH Policy All credentialed professionals will read and agree to abide by DCH policy regarding other employment.

XXIV. CONFLICT OF INTEREST
The Georgia WIC Program does not support conflict of interest at the state Districts or local levels. Based on DCH policy, all employees must report outside employment to their immediate supervisor. A determination will be made whether or not this employment opportunity is a conflict. A definitive time frame for employment will be agreed upon between the employee and his/her immediate supervisor. This will be documented in the employee's personnel file.

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The State and local agency must prohibit the following certification practices or provide alternative policies and procedures when such prohibition is not possible: (1) Certifying oneself;
(2) Certifying relatives or close friends or; (3) On employee determining eligibility for all certification criteria and
issuing food instruments for some participants. (See Food Delivery Section III. F and Certification Section III. E.) for the current procedures.

XXV. RENOVATIONS
Any capital improvements exceeding $4,999 must have prior approval from the State WIC Program and USDA. Capital Improvements are any improvements that can be decreased such as buildings, renovations, etc.).

XXVI. INTER/INTRA AGENCY AGREEMENT
The Inter/Intra Agency Agreement is an agreement that must be used by all multi-county Health Districts with each of their counties. Your District may add additional terms but must not delete or change any of the existing terms.

XXVII. PATIENT FLOW ANALYSIS
A Patient Flow Analysis (PFA) is optional and is a tool to analyze the following: 1. The range of time for certification of clients from sign-in to first face-to-
face visit where service provided. 2. The range of time for certification of clients from sign-in to exit. 3. The range of time for clients scheduled for issuance of vouchers. 4. Clinic bottlenecks. 5. Whether clients are seen in the order of appointments? 6. Are clients scheduled at a rate appropriate for services received and staff
availability? 7. Are there down times for any staff? 8. Are the appropriate staff present for first a.m. appointments? 9. How many appointments were there? Number of no-shows? (See Attachment AD12 for the PFA options)
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Procedures for the Patient Flow Analysis consist of the following two options:
OPTION I Option I contains four (4) forms which include: 1) Patient Flow Analysis (PFA) Sign-In Sheet 2) Patient Flow Analysis (PFA) Form 3) Employee Time Log 4) Questions to Answer from the Modified PFA Form
FORM I - PATIENT FLOW ANALYSIS SIGN-IN SHEET
The Patient Flow Analysis Sign-In Sheet is designed to have all WIC applicants/participants sign in at the time of arrival. Each applicant/participant must sign-in and document the arrival time.
FORM II - CLINIC FLOW ANALYSIS FORM
The Clinic Flow Analysis form documents the following:
1. Room # (if applicable) - Room number is completed in the event a clinic is divided by alphabets and each staff person is keeping his/her own SignIn form.

2. Clinic - List the name of the clinic where the analysis is being conducted.

3. Patient # - Documents the number that is assigned on the Patient Flow Analysis Sign-In Form.

4. Name - Documents the name of the applicant/participant.

5. Date Seen - Documents the actual date the Patient Flow Analysis is taking place.

6. WIC Type P __ N __ B __ I __ C
Place a check mark by the category which identifies whether the applicant/participant is a pregnant (P), postpartum (N) or breastfeeding women (B), infant (I) or child (C).

7. Reason for Visit - Documents the reason the applicant/ participant made a visit to the WIC clinic.

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Reason for Visit Codes Definitions Initial Certification Recertification (Subsequent) Incomplete Certification (i.e. - Client left without completing certification process) Reinstate Transfer Education (with or without vouchers) Special Formula or Formula Change Vouchers only (no nutrition education) Other (please specify)
8. Appointment Time - Documents appointment time of the applicant/participant.
9. Time Started - Documents the actual time that the clinic staff begins to work with the WIC participant.
10. Time Finished - Documents the actual time that staff finishes working with the applicant/participant.
11. Staff Initials - Staff that serves the WIC applicant/participant list their initials.
Note: a. A record of the staff person's initials must be placed with the actual Patient Flow Analysis documentation for audit purposes.
b. Each applicant/participant must have his/her own Patient Flow Analysis Form. Each family member must have his/her own form.
12. Patient Arrived - Actual time that participant signed in at the clinic.
13. Time Patient Left - Documents the time the applicant completes all WIC services and is leaving the clinic.
14. Total Time in Clinic - Documents the amount of time from arrival to departure for applicant/participant to receive WIC services.

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GA WIC 2010 PROCEDURES MANUAL

Administrative

15. Food Package Change (FPC)/Formula Type (optional) - Document the FPC or formula type if applicable for District use.
16. Special Services Provided/Comments - Documents any special services or circumstances which may cause you to take additional time with the applicant/participant.
FORM III Employee Time Log
The Employee Time Log form documents the following:
1. Name and Title of Employee Employee who is providing services must document their name and official title.
2. Work Hours - Employee must document their schedule work hours including the time spent servicing a client doing the clinical work, administrative work and clerical work. In addition, if an employee is working in the clinic and providing other services that does not require face to face work with the client, that time must be documented. For example, an employee working at the file room or making/receiving work related phone calls or doing administrative work.
3. Miscellaneous Any other duties the employee performed during the day of Patient Flow Analysis.
4. Lunch/ Break Employee must document the time taken for lunch or break during the day of Patient Flow Analysis.
FORM IV - QUESTIONS TO ANSWER FROM THE MODIFIED PFA
Questions from the modified PFA are listed on this form to indicate the type of information you can expect to receive from the PFA.
OPTION II
Option II contains seven (7) forms which include: 1) Patient Flow Analysis (PFA) Sign In Form 2) Personnel Identification Codes 3) Reason for Visit Code Form
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GA WIC 2010 PROCEDURES MANUAL

Administrative

4) Patient Category Form 5) Patient Register Form 6) Employee Time Log 7) Questions to Answer from the Modified PFA Form

(See Attachment AD - 12 for PFA options)
FORM I - PATIENT FLOW ANALYSIS (PFA) SIGN-IN SHEET
The Patient Flow Analysis (PFA) Sign-In Sheet is designed to have all WIC applicants / participants sign in at the time of arrival. Each applicant/participant must sign-in and document their arrival time.
FORM II - PERSONNEL IDENTIFICATION CODE FORM
The Personnel Identification Code is used to identify clinic staff/title involved (i.e., R.N.) in the PFA. A letter from the alphabet must be assigned to each employee before the PFA begins. This form must be completed at the beginning of the Patient Flow Analysis so that each clinic staff is aware of what code is assigned to them to use for the PFA.
FORM III - REASON FOR VISIT CODES
The Reason for Visit Code is used to identify the type of services being rendered to the WIC applicant/participant.
FORM IV PATIENT CATEGORY FORM
The client category identifies the codes you must use to identify the type of clients you are serving during the PFA.
FORM V - PATIENT REGISTER FORM
The Patient Register Form is to be placed on the record of each participant as they sign in, unless the participant is in the clinic for voucher pick-up only and the record is not routinely pulled. The Patient Register Form documents the following: 1. Patient Number (Should match the number on the sign in sheet). 2. Reason for visit (See Reason for Visit Codes). 3. Patient Category (See Form IV, Patient Category Form). 4. Time of Arrival (Same as sign in sheet).

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Administrative

5. Time of clinic appointment (Same as sign in sheet).
6. Patient Service Time: a. Contact number (Must match the number on the Participant Sign-in Form). b. Personnel ID code form (Must list the staff persons involved in the PF Analysis Form II). c. Start Time (Time identified on the sign in sheet Form I). d. End Time (Time services are completed). e. Service provided (See the reason for visit code Form III).

FORM VI EMPLOYEE TIME LOG
The Employee Time Log form documents the following:
1. Name and Title of Employee Employee who is providing services must document their name and official title.
2. Work Hours - Employee must document their schedule work hours including the time spent servicing a client doing the clinical work, administrative work and clerical work. In addition, if an employee is working in the clinic and providing other services that does not require face to face work with the client, that time must be documented. For example, an employee working at the file room or making/receiving work related phone calls or doing administrative work.
3. Miscellaneous Any other duties the employee performed during the day of Patient Flow Analysis.
4. Lunch/ Break Employee must document the time taken for lunch or break during the day of Patient Flow Analysis.
FORM VII - QUESTIONS TO ANSWER FROM THE MODIFIED PFA
Questions from the modified PFA are listed on this form to indicate the type of information you can expect to receive from the PFA.

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-1

ANNEX J
SFY 2010
STATE OF GEORGIA DEPARTMENT OF HUMAN RESOURCES DIVISION OF PUBLIC HEALTH AGREEMENT
FOR THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM
FOR WOMEN, INFANTS AND CHILDREN (WIC)
PROGRAM NAME: WIC, WIC Farmer's Market Nutrition Program, WIC Breastfeeding Peer Counseling
PROGRAM CODE: 301, 007, 009, 643, 254, 329
PURPOSE: The mission of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is to improve the health of low-income women, infants and children up to age 5; who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating and referrals to health care. The mission of the (WIC) Program is to provide policy direction and technical assistance to ensure continuity in program administration, operation, and compliance with program regulations, policies and procedures. The intent of the Grant InAid is to support the efforts of local agencies to provide WIC program services.
RATIONALE: WIC benefits are available to eligible pregnant or postpartum women, infants, and children up to age 5. Eligible participants must have an income at or below 185% of the US Poverty Income Guidelines; be a state resident and be at nutritional or medical risk, as determined by a health professional.
In FFY 2008, the Georgia WIC Program provided benefits to 305,516 average participants each month; 146,919 children, 80,695 infants, 23,697 prenatal women, 21,612 breastfeeding and 32,591 non-breastfeeding women.
In Georgia, WIC services are provided in all 159 counties. Services are provided at over 265 health clinics including: 16 hospitals, 5 Military Base Clinics, 4 Division of Family and Children Services (DFACS) offices and via in-home certifications. In FFY 2008, there were over 1,628 authorized food retailers that participated in the WIC food delivery system.
Services
WIC provides the following services: nutrition assessments, health screenings, medical history, body measurements (weight and height), hemoglobin checks, nutrition education, breastfeeding support and education, and vouchers for food supplements.
PUBLIC HEALTH PRIORITY FOCUS: Improved Birth Outcomes Improved Healthy Behaviors

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-1 (cont'd)

FUNDING RESTRICTIONS: Administrative costs may not be charged to this program unless the Department's Office of Financial Services has approved a cost allocation plan. OUTCOMES, PERFORMANCE, RESULTS MEASURES:
x Public Health Priority Outcome x Outcome I: Improved Birth Outcomes
Performance Measure: Number of prenatal women enrolled in the WIC program within the first trimester of pregnancy and referred for early prenatal care will increase by 1% from previous year. Performance Measure: Overall monthly WIC participation of pregnant women will increase by 4% from the previous year. Results Measures: 1) Documented 1% increase in percentage of women enrolled in the WIC program
within the first trimester of pregnancy. 2) Documented increase in average monthly participation of pregnant women in
the WIC program by 4%. 3) Documented increase in the percentage of infants enrolled in the WIC program
within the first six weeks of life by 1%.
Outcome II: Improved Healthy Behaviors Performance Measures: 1) Percentage of postpartum women in the WIC program initiating breastfeeding will increase by 2% over the previous year. 2) Percentage of children ages 2-5 in the WIC program that are within normal weight range will increase by 1% over the previous year. Results Measures: 1) Documented 2% average increase in the percentage of WIC postpartum women who breastfeed their infants for at least six months. 2) Documented 1% average decrease in the percentage of children ages 2-5 that are either overweight or at risk for becoming overweight in the WIC program. 3) Increase average monthly participation of infants in the WIC program by 4%. 4) Increase percentage of eligible children retained on the WIC program after their second birthday by 1%.
x Fund Source Outcome WIC Program eligibility is prescribed in the Code of the Federal Regulations (CFR) Title 7 Part 246. To be eligible for participation in the WIC Program, clients must meet income and categorical eligibility requirements. Eligible clients include women, infants and children up to age five (5) years who are at or below 185% of the federal poverty level and have a medical or nutritional risk. Residents and migrants meeting these requirements can be offered program benefits.

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-1 (cont'd)

PROGRAM EXPECTATIONS
1. Provide services in accordance with the Child Nutrition Act of 1966, as amended by Public Law 108 for the delivery of services for the Women, Infants and Children (WIC) Program. This provider agreement is made pursuant to the Georgia Department of Human Resources (DHR) Administrative Policy and Procedures Manual, Part II A.l., and the United States Department of Agriculture/Food and Nutrition Services (USDA/FNS) regulations being 7CFR 246, The Georgia WIC Policy and Procedures Manual, the Georgia WIC Program State Plan, the Georgia WIC Program Guidance for Local Agency Planning, and all administered memos. (The aforementioned documents are hereinafter incorporated into the agreement.)
2. Collect client data for WIC participants for the purpose of monitoring and program performance. Comply with all federal and state requirements in the collection of program data and make modifications as appropriate or requested within a specified time.
3. Employ appropriate staff to adequately perform WIC responsibilities in accordance with WIC staffing and processing standards, certification requirements, program integrity, and voucher accountability and security.
4. Participate in the development of the Georgia WIC State Plan that is annually submitted to USDA. Submit a local agency program plan to the WIC Branch that includes a status report of the previous year's accomplishments and a plan for the next year's activities by March 31st for inclusion in the annual state plan.
5. Provide WIC Farmer's Market Nutrition Program services according to the federal regulations 7 CFR 248 and the state WIC Farmer's Market Handbook.
6. Ensure that no individual is discriminated against on the basis of disability in the full and equal enjoyment of WIC services and facilities or accommodations of any place that provides such services as expressed in the Americans with Disabilities Act, Title III Sec.12182 (a).
7. Beginning, with the October 2009 closeout (December 2009), un-reconciled vouchers totaling over $100.00 at the District level maybe considered an audit exception subject to disallowance.
DELIVERABLES
1. Submit accurate and complete client data for WIC participants to the WIC data processing contractor on a daily basis or when clinic activity has occurred for the purpose of monitoring and program performance.
2. Submit an annual report identifying the status of the previous year's accomplishments and a plan for the next year's activities to be included in the State Plan.
3. Submit annual budget and county intra-agency agreements by August 1 for SFY (July-June).

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-1 (cont'd)

REPORTING REQUIREMENTS:
1) Submission of an annual report by the last business day of March for the previous Federal Fiscal Year (October thru September).
2) Submission of annual budget and county intra-agency agreements for the State Fiscal Year (July-June). Submit the report to Samuel Sims, WIC Financial, sxsims@dhr.state.ga.us.
TECHNICAL ASSISTANCE AND TRAINING:
The State Office agrees:
1. To provide technical assistance, consultation, patient flow analysis and training as needed based on request, program performance, site visits, and program reviews.
2. To allocate Nutrition Services Administration (NSA) funds to the Local Agency for use in meeting reimbursed allowable WIC administrative, nutrition education, breastfeeding and client service expenses of the Local Agency.
3. To pay cost for food vouchers issued by the Local Agency and redeemed by participating
authorized vendors for eligible participants.
4. To monitor and evaluate the Local Agency to insure maximum effectiveness and efficiency; and to provide technical assistance, consultation and training to improve performance.
5. To provide specific manuals, forms, and nutrition education materials required for operation of the program.
6. To conduct independent verification and validation that local WIC data system modifications are performing as expected and/or to ensure system modifications are in place and are operating in accordance with federal and state program regulations and guidelines.

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-2

GEORGIA WIC PROGRAM

EQUIPMENT STATUS CHANGE FORM/TRANSFER FORM & INVOICE

Action Request

Transfer Surplus Destruction Stolen Missing Description Change Other (Specify) ___________________________

FOR SURPLUS PROPERTY SECTION
USE ONLY

Requesting/Releasing Organization

Receiving Organization

Org #:

Locator #

Division/Office/Unit Name

Org #:

Locator #

Division/Office/Unit Name

Transaction Number

Street/P.O. Box City Auth Signature/Date

State

Zip Phone

Street/P.O. Box City Auth Signature/Date

State

Zip

Phone

Line Quan. Decal No. Item
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 COMMENTS:

Description (Including Make, Model, Serial Number, Etc.)

Condition Funding Good, Fair Info. Poor, Scrap

Final Disposition

Approved:

Released By:

Received By:

____________________________
Supervisor, Surplus Property Section _______________________________
Date

_______________________________
Division Property Supervisor
_______________________________
Property/Vehicle Management Unit
_______________________________
Date

____________________________________ Signature
____________________________________ Title
____________________________________ Date

INSTRUCTIONS: Releasing Agency should prepare this form prior to actual transfer to Surplus Property Warehouse.

Copies will be distributed by the Surplus Property Section.

Requesting Organization should keep Last Copy (Goldenrod)

Revised 08/09

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-3

AGREEMENT FOR DISCLOSURE OF INFORMATION BETWEEN
THE GEORGIA DIVISION OF PUBLIC HEALTH WIC PROGRAM and _________________________________

THIS AGREEMENT is entered into between the Georgia Division of Public Health for the Special Supplemental Nutrition Program for Women, Infants, and Children, (hereinafter referred to as "WIC"), and _________________________________ (hereinafter referred to as the "Receiving Organization").
This agreement is entered into by both parties in accordance with Federal Regulation 7 CFR 246.26(d) which allows for the disclosure of specific WIC applicant and participant information (current and historical) for the purpose of (1) establishing the eligibility of the WIC applicants or participants for health or public assistance programs; and (2) conducting outreach to WIC applicants and participants. This agreement will be in effect for one year or until a written request is submitted by either agency to modify or cancel it.
THE PARTIES AGREE:
A. WIC agrees:
1. To provide the following applicant or participant information to the Receiving Organization as needed: information on the WIC Assessment/Certification Form or in the computer system including, but not limited to, name, address, phone number, ethnic origin, and birthdate;
2. Not to provide Medical data.
B. Receiving Organization agrees:
1. That the WIC Program information may be used only for the purpose of establishing the eligibility of WIC applicants and participants for health or welfare programs administered by the Receiving Organization, and for the purpose of conducting outreach to WIC applicants and participants for such programs.
2. The Receiving Organization agrees and assures that it will not disclose information provided by WIC under this agreement to a third party and that it will resist others efforts to obtain this information. It further assures that it will restrict the use or disclosure of WIC program information according to WIC guidelines, including 7 CFR 246.26(d).

________________________________
Miriam Bell, MPH
Division of Public Health
_______________________________________ DATE

_________________________________
Director
______________________________________ Receiving Organization
______________________________________ DATE

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GA WIC 2009 PROCEDURES MANUAL

Attachment AD-4

RELEASE OF INFORMATION FORM

Georgia Department of Human Resources

__________________________________________
Name of Client/Patient/Applicant

__________________________________________
Date of Birth

IF AVAILABLE:

___________________
ID Number Used by Requesting Agency

_______________
ID Number used by Releasing Agency

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request and authorize: _________________________________________________________________
(Name of Person or Agency Requesting Information)
____________________________________________________________________________________________
(Address)
to obtain from: _______________________________________________________________________________
(Name of Person or Agency Holding the Information)
____________________________________________________________________________________________
(Address)
the following type(s) of information from my records (and any specific portion thereof): ____________________________________________________________________________________________
____________________________________________________________________________________________
for the purpose of: __________________________________________________________________________
____________________________________________________________________________________________

All information I hereby authorize to be obtained from this agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect for:
[ ] ninety (90) days unless I specify an earlier expiration date here:_________________ .
(Date)
[ ] one (1) year.

[ ] the period necessary to complete all transactions on accounts related to services provided to me.

I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time.

________________________________________
(Date)

__________________________________________
(Signature of Client/Patient/Applicant)

________________________________________
(Signature of Witness) (Title or relationship to Client)

__________________________________________

(Signature of Parent or Authorized

(Date)

Representative, where applicable)

USE THIS SPACE ONLY IF CLIENT WITHDRAWS CONSENT

______________________________________
(Date this consent is revoked by client)

__________________________________
(Signature of Client)

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-5

GEORGIA WIC PROGRAM

REQUEST TO ESTABLISH NEW CLINICS/CLINIC CHANGE

PURPOSE OF REQUEST: EST. NEW CLINIC EFFECTIVE DATE OF CHANGE

CLINIC CHANGE CLINIC NUMBER

TYPE OF CHANGE

DIST/UNIT

DATE SUBMITTED

COUNTY#

COORDINATOR

CONTRACT # (IF LOCATED OUTSIDE OF HEALTH DEPT.)

CONTACT PERSON

NEW CLINIC NAME

MAILING ADDRESS (not a Post Office Box)

PHONE#

ATTENTION:

CLINIC DAYS AND HOURS OF OPERATION

PURPOSE OF PROPOSED CLINIC (circle) initial certification re-certification nutrition education voucher issuance

Other (specify)

SCHEDULE OF VOUCHER ISSUANCE (circle)

monthly

bi-monthly odd

bi-monthly even

PLEASE INDICATE IF TADS & VOUCHERS ARE TO BE SHIPPED TO ANOTHER LOCATION OTHER THAN THIS CLINIC

VOUCHER ORDERS SPECIAL VOUCHERS BLANK VOUCHERS

TAD ORDERS BLANK TADS ___________________________________ PREPRINTED TADS______________________________

PREPRINTED VOUCHER PACKAGES

WOMEN (P&B) INFANTS

_________________ PACKAGES _________________ PACKAGES

WOMEN (N) CHILDREN

_______________ PACKAGES _______________ PACKAGES

PLEASE INDICATE A BEGINNING TAD NUMBER (EXAMPLE: CLINIC #123 WOULD BE 123000001 FOR THE BEGINNING TAD NUMBER) ____________________________________________________________________________

COVANSYS WILL ASSIGN A MAXIMUM NUMBER OF INDIVIDUAL VOUCHERS TO BE PRINTED. THIS NUMBER WILL EQUATE

TO 100 PACKAGES FOR WOMEN, 100 PACKAGES FOR INFANTS AND 100 PACKAGES FOR CHILDREN. IF YOU WISH TO

INCREASE THIS NUMBER, PLEASE INDICATE: YES

NO

FOR STATE WIC BRANCH USE

APPROVED

DISAPPROVED

FOR COVANSYS USE

NEW CLINIC # ASSIGNED

__________________________________________________________

EFFECTIVE DATE

__________________________________________________________

COMPLETED BY

__________________________________________________________

SYSTEM MAINTENANCE REPORT #

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-6

Date submitted: Clinic number:

GEORGIA WIC PROGRAM COMPUTER SYSTEM ISSUES and PROBLEMS REPORT
Date problem discovered:
District/unit number:

Name of person reporting issue: Telephone number: Name of person experiencing issue: Telephone number:

Position: Email: Position: Email:

Directions: Type an X next to selections and email to the Systems Information Unit or fax to (404) 657-2910.

Severity of problem (select one)
Extremely critical
Critical
Major

Problem type: (select one and describe below)

Batching problem Provide Batch number Incorrect information in system
Equipment malfunction

Voided voucher numbers (list)
Multiple copies of same voucher printed ( ) times Voucher number error

Average

Printer problem

Same voucher number(s) given to different client(s)

Minor

System down (failure)

Vouchers did not print

Enhancement

System slow

Voucher format error

Farmer's Market

Update system information needed Computer virus (type)

Vouchers printed to wrong destination Other

Describe the issue and proposed solution (include voucher numbers if applicable):

Did staff report this issue to anyone? Yes____ No____

If yes, provide name and telephone number: _________________

Status since report (circle): Resolved

Unresolved

Computer report potentially affected: (e.g. CUR) _________

Reason for reporting to state WIC Office (circle): FYI only

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Pending Take Action

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-7

NEW SITE PERMISSION FORM

TO: FROM: DATE: RE:

District Health Directors Georgia WIC Director XX XX, 200_ Permission To Open A New WIC Site.

The Georgia WIC Program Review Team has completed the site(s) visit located at:

Based on this visit the District site(s) listed above: May Open: ____________________ May Not Open: ________________
If you have any questions, please contact the Policy Unit at (404) 657-2900.

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-8

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-9

_NEW CLINIC EVALUATION REPORT_
Health District: Clinic: Date:
Satisfactory = S Unsatisfactory = U Recommendation = R Not Applicable = NA Satisfactory, Needs Improvement = SN
This New Clinic Evaluation Report will be used to ensure uniformed adherence to clinic set up specifications. A written summary of activities must be submitted and approved before the clinic in question can officially be opened.

NEW CLINIC SITE PART I PROGRAMMATIC
A. Location of Records Are participant records kept on file?
B. Documentation of Transfer Methods How are participants transferred?
C. Security (ID Card, WIC Stamp, VOC Cards, VOC Card Log) Are security procedures being followed?
D. Equipment in Place with Inventory Numbers Is WIC purchased equipment accurately identified?
E. Policy Memos
Does the new clinic have a copy of all policy memos on file?
F. Procedures Manual
Is a current Procedures Manual located in the clinic?
G. Poster (No Smoking, Civil Rights, LEP, and No Charge)
Are required posters displayed in the clinic?
H. Certification Form
Are current certification forms available?
I. Certification Process
Are policies and procedures followed during the certification process?
J. Processing Standards
Are staff aware of WIC processing standards timeframes?

S U R NA SN

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE

S

K. Clinic Hours of Operation (after hours one day a week)
What are the clinic's hours of operation?

L. Agreement with the WIC Branch/District/Hospital
Does the Coordinator/District Office/WIC Branch have a signed copy of the agreement on file?

M. Civil Rights
Has staff been trained in the area of Civil Rights? Note: 1. Demographics of the population to be served in order to evaluate program access Racial makeup of the area you will be serving and who will be attending the clinic. A public health website that may be used to collect this information is http://oasis.state.ga.us/. 2. Data collected regarding covered employment including use of bilingual public-contact employees serving LEP (Limited English Speaking) beneficiaries of the programs Racial ethnic data of the employees that will be working at the new clinic. 3. Evaluation of the location of existing or proposed facilities connected with the program and whether access would be difficult or impossible because of locale Is there anyone who would be denied services due to the facility and racial makeup of the clinic. 4. Review of the composition of the planning or advisory board
Racial makeup of the new facility.
5. Analysis of civil rights impact, if relocation of the clinic is involved Provide an analysis of the new location. This only applies when
the clinic is relocating.
6. A written assurance by any program applicant or recipient that it will compile and maintain records required by the (FNS) Food
Nutrition Service guidelines or other directives.
7. The manner in which services are or will be provided by the program in question, and related data necessary for determining whether any persons are or will be denied such services on the basis
of prohibited discrimination.
8. A statement of notification from the program applicant or recipient to promptly notify (FNS) Food Nutrition Service of any lawsuit filed against the program applicant or recipient or sub recipient alleging discrimination on the basis of race, color, or national origin and that each recipient notify (FNS) Food Nutrition Service of any complaints filed against the recipient alleging such discrimination; and that each program applicant or recipient provide a brief description of any pending application to other Federal agencies for assistance, and of Federal assistance being provided at time of application or requested report .
9. A statement or description of previous civil rights reviews regarding the program applicant two years prior to applying as well as any information about the agency or organization performing the review and any periodic statements by the recipient regarding such reviews.

* Please note that a program applicant or recipient is the entity applying for program funding to serve WIC participants.

U R NA SN

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE Part II COMPLIANCE ANALYSIS A. Voucher Inventory
The VPOD and Manual inventory must be conducted for all vouchers issued to participants.
B. Voucher Security
Vouchers must be stored in safe and secure location.
C. Printer Security
Printers must not be accessible to participants or any unauthorized personnel.
D. Voucher Transport on Clipboards
Voucher in hospital setting can be transport in a locked clipboard, lockbox, or locked briefcase.
E. Issuance Space
Adequate space for issuing vouchers to participant with security of vouchers maintained.
F. Voucher Storage
Vouchers must be stored in a secure location at all times.
PART III NUTRITION SECTION A. Anthropometrics
1. Height Board Meeting Standards? 2. Length Board Meeting Standards? 3. Adult Scales Meeting Standards/Certified within Last Year? 4. Infant Scales Meeting Standards/Certified within Last Year?
B. Growth Charts
1. Birth-36 months and 2-20 Years for Boys and Girls? 2. Prenatal Weight Gain Grid?
C. Certification
1. Hemoglobin/Hematocrit Procedures for Evaluation? 2. Dietary Assessment Sheets? 3. Certification Forms? 4. Computer Certification?
D. Staff Interviews
1. Nutritionist 2. Clerk 3. Nurse 4. Nutrition Assistant

S U R NA SN

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE E. Staff Training
1. Nutritionist 2. Clerk 3. Nurse 4. Nutrition Assistant
F. Breastfeeding Promotion and Support (friendly environment)?

S U R NA SN

G. Adequate Space to Work?

H. Adequate Space for Counseling?

I. Adequate Space for Voucher Issuance/Waiting Room?

J. Patient Confidentiality?

K. Clinic Flow?

L. Resources
1. Nutrition Education Materials (provide list of materials available at clinic site)?
2. Nutrition Education Materials Ordering Catalog (describe process for ordering nutrition education materials)?
3. Nutrition Guidelines for Practice? 4. Risk Criteria Handbook? 5. Calculator?
PART IV SYSTEMS INFORMATION A. Clinic Information
1. Clinic Number 2. Full VPOD 3. WIC Computers 4. Clinic Staff Authorized to Use WIC System 5. Clinic Supervisors Listed 6. Current Authorized Users Kept on a List 7. Non-clinic Staff Authorized to Use WIC System Listed 8. Terminated or Transferred Staff Still on the List

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE

S U R NA SN

B. Physical Security
1. Computer, Printer and Voucher Stock in a Safe Area

2. Computer is Locked in a Safe Area when Clinic is Closed

C. Program Security
1. System Backed Up Daily?

2. Provisions for Storing Backup Files in Case of Fire or Other Disasters?

3. Users No Longer Employed by WIC Deleted from the System?

4. List of Users and their Passwords Kept in the Clinic (No such list should be kept anywhere)?

5. Clinic Maintains a Supply of Both Blank and Pre-numbered Paper TADs for Use in Emergencies?

6. Clinic Maintains a Supply of Blank Manual Vouchers for Use in Emergencies?

7. Clinic Maintains a Supply of Blank Standard Vouchers for All WIC Types as well as Blank Manual (999 series) Vouchers for Use in Emergencies?

8. Acknowledgement Dates for ETAD and Voucher Batches are Posted?

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

Comments/Observed Strengths and Weaknesses:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_________________________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________
WIC Coordinator/Clinic Manager
For State Agency Use Only
_____________________________ State Staff Receiving Signature

______________
Date Completed

_______________________
Date Submitted to the State
_______________________ Date Received by the State

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-10

STAFFING PATTERNS FORM

List the number of types of staff located in your District who work with the WIC Program:

Staff

How many?

Nutritionist LPN (WIC) Lactation Consultants Administrative Staff Health Techs Clerks Para professions Health Associates Registered Nurse (RN) Lab Technicians Program Assistants Nutrition Assistants Breastfeeding Coordinator WIC Coordinator Others: _________________
write in title

___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Looking for: The number and types of staff that administers the WIC Program in each District.

AD-71

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-11

Nutrition Services Director Job Description
Under broad supervision of the District Health Director and/or the District Program Manager, plans, implements, monitors, and evaluates the nutrition services of a Public Health District and WIC Program services to include certification section, rights and obligations section, administrative section, vendor section, food package section, nutrition education section, special population section, outreach section, food delivery section, compliance section, monitoring section, breastfeeding section, computer system section and disaster plan section.
Job Responsibilities and Performance Standards:
I. Advises and collaborates with the agency health official, senior policy makers, administrators and legislators who have a significant impact on the mission, programs and policies in the District Health Agency. (Performed by all incumbents) 1. Participates in the development of health policies as a member of the health agency's management team. 2. Reviews and comments on proposed legislation, regulations, and guidelines promulgated by federal, state and local legislative bodies and regulator agencies and evaluates potential impact on health agency performance and environment. 3. Participates in development, implementation and compliance with nutrition standards of care and quality assurance throughout health agency. 4. Collaborates with community agencies or groups and provide nutrition outreach and educational information as needed.
II. Develops long and short term goals for the health agency and participates in the agency's strategic and operational planning. (Performed by all incumbents) 1. Identifies programs and services to be implemented. 2. Conducts agency and community assessments. Uses health and management information databases in decision making. 3. Identifies available and needed nutrition resources for the target population. Plans future directions by coordinating and writing the State Administrative/Nutrition Education Plans. 4. Approves the district's nutrition plan within established time frames.
III. Prepares the agency's multi-million dollar nutrition services budget (i.e., WIC, Medicaid, other third party reimbursements and contract funds) and prepares grant proposals and contracts to obtain funds for expansion of nutrition services. (Performed by all incumbents) 1. Budgets multiple source nutrition funding, (i.e., WIC, Medicaid, other third

AD-72

GA WIC 2009 PROCEDURES MANUAL

Attachment AD-11 (cont'd)

party reimbursements, grant and contract funds) in compliance with federal, state and local standards. 2. Monitors expenditures to ensure conformity to budget category allowance. Identifies potential cost overruns. 3. Administers grants and contracts for nutrition services according to applicable laws and guidelines.
IV. Participates as an active member of the agency management team and recommends health program utilization and implementation strategies. (Performed by all incumbents) 1. Accurately determines staffing, facility and equipment needs. Coordinates staff activities, assign work and set priorities and deadlines for staff. 2. Provides appropriate input in the design and implementation of the agency management information system. 3. Thoroughly evaluates and monitors nutrition services outcomes for budget justification and for program compliance. 4. Conducts self-reviews annually using the "State of Georgia WIC Branch Local Agency Monitoring Tool" to evaluate operations and to document findings for usage at the State level and Local level. 5. Participates as a member of the District Health Emergency Assistance and Resource Team (DHEART).
V. Provides expert nutrition information on technical application of nutrition expertise to agency and community administrators, policy makers and advocacy groups. (Performed by all incumbents) 1. Provides timely responses to inquiries regarding nutrition information by human service professionals, related community volunteer agencies and/or educators or academic. 2. Provides nutrition policy analysis and interpretation to administrators, legislators and/or corporate/industry inquiries as needed. 3. Collaborates as agency representative in community advocacy or volunteer agencies, providing nutrition and health educational information and agency support. 4. Responsible for researching and providing training opportunities to nutrition competency for nutritionists, public health nurses and other health care workers. 5. Responsible for overseeing breastfeeding trainings and to attend biannual coalition meetings.
VI. Creates and maintains a high performance environment characterized by positive leadership and a strong team orientation. (Performed by all incumbents) 1. Define goals and/or required results at beginning of performance period and gains acceptance of ideas by creating a shared vision.

AD-73

GA WIC 2009 PROCEDURES MANUAL

Attachment AD-11 (cont'd)

2. Communicates regularly with staff on progress toward defined goals and/or required results providing specific feedback and initiating corrective action when defined goals and/or required results are not met.
3. Confers regularly with staff and supervision to review employee relation's climate, specific problem areas and actions necessary for improvement.
4. Evaluates employees at scheduled intervals; obtains and considers all relevant information in evaluations and supports staff by giving praise and constructive criticism.
5. Recognizes contributions and celebrate accomplishments. 6. Motivates staff to improve quantity and quality of work performed and
provides training and development opportunities as appropriate.
VII. Manages human resource and employee relation's functions. (Performed by all incumbents) 1. Interviews applicants or employees to fill vacancies or promotional positions according to applicable laws, rules and policies. 2. Selects or promotes the appropriate number of individuals who possess the skills needed to perform required work. 3. Provides orientation to new employees. Identifies training needs and ensure that necessary job-related instruction is provided to all staff. 4. Discusses potential grievance-related concerns with employees in order to identify options or resolve issues prior to the formal filing of a grievance. 5. Advises employees of established grievance procedures. 6. Recommends or initiates disciplinary actions according to applicable rules and policies.
VIII. Maintains responsibility for personal professional continuing education to enable application of current professional practice. (Performed by all incumbents) 1. Participates in professional workshops, seminars, nutrition staff meetings and other in-services as scheduled. Summarizes relevant information received in the training sessions and shares with other staff either in verbal or written form. 2. Remains knowledgeable and up-to-date in the field of nutrition through reading nutrition and medical journals and textbooks. 3. Maintains CPR certification and proficiency by renewing certification biannually.

AD-74

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12

FORM I

PATIENT FLOW ANALYSIS (PFA) SIGN IN

OPTION I

Clinic

Date ____________ Start Time ___________

Patient Number

Name

Arrival Time

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20
(See instructions for PFA in the Administration section of the Procedures Manual)

AD-75

GA WIC 2010 PROCEDURES MANUAL
FORM II
Patient Flow Analysis (PFA) Form
Room #: __________________ (If Applicable) Clinic: _________________________________________ Patient #: _______________________________________ Name: _________________________________________ Date Sent:_______________________________________ Reason for Visit: ________________________________ WIC Type: _____ P______ N_____B _____ I _______ C Appointment Time: _____________________________

Attachment AD-12 (cont'd) OPTION I

Time

Time Started Initials

Time

Staff

Finished

Patient Arrived:

____

Initiate Worker:

____

_____

____

Clerk:

____

_____

____

Lab Worker:

____

_____

____

Nurse:

____

_____

____

Nutritionist:

____

_____

____

Clerk:

____

_____

____

Time Patient Left:

____

Total Time in Clinic:

____

FPC/Formula Type: (Optional) ________________________________________________

Special Services Provided/Comments: ___________________________________________

______________________________________________________________________________

Note: 1. 2.

A record of staff initials must be kept on file for audit purposes. Each applicant/participant must have her/his own PFA Form.

AD-76

GA WIC 2010 PROCEDURES MANUAL FORM III

Attachment AD-12 (cont'd) OPTION I

Patient Flow Analysis: Employee Time Log

Name & Title of Employee

_________________________

Work Hours (Serving Participant in the Clinic):

Clinical:

_________________________

Administrative:

_________________________

Clerical:

__________________________

Work Hours (Serving Participant outside of Clinic, ie phone/appt/Dr. office):

Clinical:

_________________________

Administrative:

_________________________

Clerical:

__________________________

Miscellaneous (any other duties perform):

__________________________

Lunch/ Break:

__________________________

AD-77

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12 (cont'd)

FORM IV

OPTION I

Questions to Answers for Option I

1. What was the length of time that a client waited from sign-in to first clinic staff contact?

2. What was the range of time for certification clients from sign-in to exit?

For clients scheduled for issuance?

3. Were there any clinic bottlenecks?

4. Are clients seen by order of appointment?

5. Are clients scheduled at a rate appropriate for services received and staff availability?

6. Are there down times for any staff?

7. Are the appropriate staff present for first morning appointments?

8. How many appointments were there? Number of no-shows?

AD-78

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12 (cont'd)

FORM I

PATIENT FLOW ANALYSIS (PFA) SIGN IN

Clinic _______________ Date ___________ Start Time ___________

Patient Number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Name

Arrival Time

OPTION II Appt. Time

(See instructions for PFA in the Certification section of the Procedures Manual)

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12 (cont'd)

FORM II
CODES A B C D E F G H I J K L M N O P Q R S T U V W

PERSONNEL IDENTIFICATION CODES

OPTION II

NAME

OFFICIAL FUNCTION

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GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12 (cont'd)

FORM III

OPTION II

REASON FOR VISIT CODES

Code A. B. C. D. E. F. G. H. I.

Definition
Initial Certification Recertification (Subsequent) Incomplete Certification (i.e. - Client left without completing certification process) Reinstate Transfer Education (with or without vouchers) Special Formula or Formula Change Vouchers only (no nutritional education) Other (please specify)

AD-81

GA WIC 2010 PROCEDURES MANUAL FORM IV

Attachment AD-12 (cont'd) OPTION II

PATIENT CATEGORY

A. Pregnant Woman B. Postpartum Woman C. Breastfeeding Woman D. Infant E. Child F. Family (use only when a combination of family members receives WIC services) G. Other (specify)

AD-82

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12 (cont'd)

FORM V

PATIENT REGISTER

OPTION II

Patient Number: ____________________________________ (from sign-in sheet) Reason for Visit: ____________________________________ Patient Category: ____________________________________ Time of Arrival: ____________________________________ (from sign-in sheet) Time of Clinic: ____________________________________ Appointment

Patient Service Time

Contact # Personnel Start Time End Time ID Code

Service Provided *

1.

______

______

______

_______________________

2.

______

______

______

_______________________

3.

______

______

______

_______________________

4.

______

______

______

_______________________

5.

______

______

______

_______________________

6.

______

______

______

_______________________

7.

______

______

______

_______________________

8.

______

______

______

_______________________

*Note: Service Provided If anything out of the ordinary occurs while serving the participant, please write in the Service Provided Column one of the items listed below that apply.

Computer Problems



Food Package Change



Multiple Family (No. ____)

Telephone Call



Customer Complaint



Interpreter



Transfer



Need Re-cert



New WIC ID Card

Verification of ID

Client Left Clinic

Address Change

Immunization



Other ________

AD-83

GA WIC 2010 PROCEDURES MANUAL FORM VI

Attachment AD-12 (cont'd) OPTION II

Patient Flow Analysis: Employee Time Log

Name & Title of Employee

__________________________

Work Hours (Serving Participant in the Clinic):

Clinical:

__________________________

Administrative:

__________________________

Clerical:

__________________________

Work Hours (Serving Participant outside of Clinic, ie phone/appt/Dr. office):

Clinical:

__________________________

Administrative:

__________________________

Clerical:

__________________________

Miscellaneous (any other duties performed): __________________________

Lunch/ Break:

__________________________

AD-84

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-12 (cont'd)

FORM VII

OPTION II

Questions to Answer from the Modified PFA

1. What was the length of time that a client waited from sign-in to first clinic staff contact?

2. What was the range of time for certification clients from sign-in to exit?

For clients scheduled for issuance?

3. Were there any clinic bottlenecks?

4. Are clients seen by order of appointment?

5. Are clients scheduled at a rate appropriate for services received and staff availability?

6. Are there down times for any staff?

7. Are the appropriate staff present for first morning appointments?

8. How many appointments were there? Number of no-shows?

AD-85

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13

INTER/INTRA AGENCY AGREEMENT

x Use Option that fits District model
AD-86

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

OPTION I
SFY 2010
INTER/INTRA AGENCY CONTRACT
BETWEEN
(LEAD COUNTY) COUNTY BOARD OF HEALTH
AND
__________COUNTY BOARD OF HEALTH
FOR
THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM (WIC)
This contract is between the (Lead County) Board of Health and the _________County Board of Health to provide services in accordance with the Child Nutrition Act of 1966, as amended by Public Law 108 for the delivery of services for the Women, Infants and Children (WIC) Program. The Lead County Board of Health agrees to distribute WIC Nutrition Services Administrative (NSA) funds based upon an assigned caseload target to the _________County Board of Health. The _________ County Board of Health must perform the following functions in order to meet WIC Program objectives: nutrition education, breastfeeding promotion and support, participant certification, caseload management, food delivery, screenings for and referrals to other social and medical service providers and general program management. This contract is made pursuant to the Georgia Department of Community Health (DCH) Administrative Policy and Procedure Manual, and the United States Department of Agriculture /Food and Nutrition Services (USDA/FNS) regulations being 7CFR246, the Georgia WIC Policy and Procedures Manual, The Georgia WIC Program State Plan, The Master Agreement, Annex J and the Georgia WIC Program Plan for Local Agency Planning, WIC Financial Management and Statewide Cost Allocation Plan, and all administrated memos. The aforementioned documents are hereinafter incorporated into this agreement.

BOTH PARTIES AGREE:
1. To adhere to the WIC Statewide Cost Allocations Plan. Maintain complete and accurate records of WIC funds received and expended, employing Generally Accepted Accounting Principles (GAAP), reconciling WIC expenditures to WIC revenue, to make these records available for audit upon request of the Georgia WIC Program, the DCH Office of Audits, the DCH Office of Investigative Service and/or the federal agency (USDA). In case of an audit exception in performance, the County Board of Health may be responsible for payment to the WIC Program from the County Agency's nonparticipating funds.

AD-87

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

(LEAD) COUNTY BOARD OF HEALTH AGREES:
1. To provide $___________ of Nutrition Services Administration (NSA) funding for the
reimbursement of non-WIC paid staff for salary and fringe only with an assigned caseload target of _________ to the ________ County Board of Health. To disburse contracted NSA funds to the _________County Board of Health in the first and second quarter of the State fiscal year. When and if additional WIC NSA funds become available, this contract must be amended using Attachment A.
2. To reimburse non-WIC paid staff for all WIC approved per diem/travel.
3. To provide medical/supplies, office supplies, equipment and any items required to perform service delivery to WIC clients.
4. To provide manuals, forms and nutrition education materials required for WIC service delivery as specified in the Georgia WIC Program Policy and Procedures Manual and the Georgia WIC Program State Plan.
5. To monitor, evaluate and provide technical assistance and training for the County Agency staff regarding the delivery of WIC services on a routine basis and/or as requested.
6. To reimburse the County for approved Central Services Cost Allocation expenditures in County Health Departments. (optional)
________________ COUNTY BOARD OF HEALTH AGREES:
1. To accept $___________ of Nutrition Services Administration (NSA) funding with an assigned WIC caseload target of______ from ________ County Board of Health. A local agency must perform the following functions in order to meet WIC Program objectives: nutrition education, breastfeeding promotion and support, participant certification, caseload management, food delivery, screenings for and referrals to other social and medical service providers and general program management.
2. To submit a projected line item budget to (Lead) ____________County within 30 days of the acceptance of this contract (Attachment A). When additional funds are allocated to the County; Attachment A must be resubmitted to the __________County Board of Health.
3. To have appropriate staff to adequately perform WIC responsibilities in accordance with WIC staffing and processing standards, certification requirements, program integrity, and voucher accountability and security;
4. To collect client data for WIC participants for the purpose of monitoring and program performance. To comply with all federal and state requirements in the collection of program data and make modification as appropriate or requested within a specified time;
5. To comply with all the fiscal and operational requirements prescribed by the State agency pursuant to 7CFR part 3016, the debarment and suspension requirements of 7 CFR part 3017, if applicable, the lobbying restrictions of 7 CFR part 3018, and FNS guidelines and instructions, and provides on a timely basis to the State agency all required information regarding fiscal and Program information;
6. To prohibit smoking in the space used to carry out the WIC Program during the time any aspect of WIC services are performed;

AD-88

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

7. To not discriminate against persons on the grounds of race, color, national origin, age, sex or handicap; compile data, maintain records, and submit reports as required to permit effective enforcement of the non-discrimination laws;

8. To maintain on file and have available for review, audit, and certification criteria used to determine program eligibility;

9. To provide the ____________ County Board of Health, the Georgia WIC Program and the DCH Office of Audits immediate and complete access to all clinics and all records maintained by WIC clinics within the County;

10. To obtain prior approval from the Lead County, for any Central Services Cost Allocation Plan and must adhere to the WIC Cost Allocation Guidelines.

ASSURANCE

This assurance is given in consideration of and for the purpose of obtaining any federal financial assistance, grants, and loans of federal funds, reimbursable expenditures, or donation of federal property and interest in property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or any improvements made with federal financial assistance extended to the program applicant by the State. This includes any federal agreement, arrangement, or other contract, which has as one of its purposes, the provision of assistance of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.

By accepting this assurance, the program applicant agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of Title VI and to permit authorized USDA personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Agriculture, Food and Nutrition Services, shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the program applicant, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the State.

Either party upon sixty (60) days written notice may terminate this service agreement. Non-renewal of this provider agreement is not cause for appeal.

The Local Agency has the right to appeal decision of the Georgia WIC Program which affects program participation as specified in 7CFR246.22, Administrative Appeals. A Local Agency is allowed two (2) opportunities to reschedule a hearing.

_______________________________ County Board of Health (Lead County)

_______________________ Date

_______________________________ County Board of Health

_______________________ Date

_______________________________ District Health Director

_______________________ Date

AD-89

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENT NUTRITION PROGRAM (WIC)

PLANNED BUDGET FOR SFY 2010

A. Personal Services B. Central Cost Allocation Plan

$______________ $______________

TOTAL
Prepared by:
___________________________________ Contractor Signature
___________________________________ Typed Name and Title
___________________________________ Date

$_____________

AD-90

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

Central Cost Allocation Plan (643) __________County Health Department
SFY '10 July 1, 2009 June 30, 2010

Purpose: The purpose of this Central Cost Allocation Plan is to arrive at an equitable distribution of common expenses reimbursable to the __________________County Board of Health from the (Lead County) County Board of Health WIC Program based on square footage of floor space.
Shared Cost: This Central Cost Plan will include reimbursement for actual cost common to WIC.
Expenses: Expenses will be based on a percentage of the actual cost and will include the following:
Percentage of Common Space allotted to WIC (Identify Space): ____________ Total square footage of building: ________________
Common Costs: x Utilities (% of actual cost based on utility bill) x Cleaning/maintenance/supplies/paper products (% of actual cost) x Annual Electric Record Room File Maintenance (%of actual cost) x Toilet paper/paper towels (% of actual cost) x A/C & Heating Repairs/Maintenance/Insurance (% of actual cost) x Garbage (% of actual cost) x Pest control (% of actual cost) x Scale Calibration (% of actual cost) x Telephone and Fax (per Phone bill) x Use of Copy Machine/Supplies (% of actual cost) x Medical Waste (% of actual cost)
Invoices must be submitted by the 5th of the month for the previous month. Reimbursement is based on WIC funding and is not guaranteed if funding is not available.

____________________________________ Lead County Board of Health, Chairperson

___________________________________ Board of Health, Chairperson

___________________________________ District Health Director

AD-91

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

OPTION II
SFY 2010
INTER/INTRA AGENCY AGREEMENT BETWEEN
(LEAD COUNTY) COUNTY BOARD OF HEALTH AND
_____________ COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN PROGRAM (WIC)
This agreement is between the (Lead County) Board of Health and the _________ County Board of Health to provide services in accordance with the Child Nutrition Act of 1966, as amended by Public Law 108 for the delivery of services for the Women, Infants and Children (WIC) program. This provider
agreement is made pursuant to the Georgia Department of Community Health (DCH) Administrative
Policy and Procedure Manual, and the United States Department of Agriculture/Food and Nutrition Services (USDA/FNS) regulations being 7CFR246, the Georgia WIC Policy and Procedural Manual, The Georgia WIC Program State Plan, The DHR Master Agreement, Annex I and the Georgia WIC Program Plan for Local Agency Planning, WIC Financial Management and Statewide Cost Allocation Plan and all administrated memos. (The aforementioned documents are hereinafter incorporated into this agreement.
THE ____________ COUNTY BOARD OF HEALTH AGREES:
1. To comply with all the fiscal and operational requirements prescribed by the State agency pursuant to this part, 7 CFR part 3016, the debarment and suspension requirements of 7 CFR part 3017, if applicable, the lobbying restrictions of 7 CFR part 3018, and FNS guidelines and instructions, and provides on a timely basis to the State agency all required information regarding fiscal and Program information;
2. To prohibit smoking in the space used to carry out the WIC Program during the time any aspect of WIC services are performed;
3. To not discriminate against persons on the grounds of race, color, national origin, age, sex or handicap; and compiles data, maintains records and submits reports as required to permit effective enforcement of the nondiscrimination laws.
4. To accept $ ____________ of Nutrition Services Administration (NSA) funding from the (Lead County) County Board of Health for the purpose of paying approved Central Services Cost. Prior approval from the (Lead County) County Board of Health must be obtained for any Central Services Cost Allocation Plan and must adhere to the Statewide Cost Allocation Plan

AD-92

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

ASSURANCE
Either party upon sixty (60) days written notice may terminate this agreement. Non-renewal of this agreement is not cause for appeal.
The Local Agency has the right to appeal decision of the Georgia WIC Program which affects program participation as specified in 7CFR246.22, Administrative Appeals. A Local Agency is allowed two (2) opportunities to reschedule a hearing.

_______________________________ County Board of Health (Lead County)

_______________________ Date

_______________________________ County Board of Health

_______________________ Date

_______________________________ District Health Director

_______________________ Date

AD-93

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENT NUTRITION PROGRAM (WIC)

PLANNED BUDGET FOR SFY 2010

A. Personal Services B. Central Cost Allocation Plan

$______________ $______________

TOTAL
Prepared by:
___________________________________ Contractor Signature
___________________________________ Typed Name and Title
___________________________________ Date

$_____________

AD-94

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-13 (cont'd)

Central Cost Allocation Plan (643) __________County Health Department
SFY '10 July 1, 2009 June 30, 2010

Purpose: The purpose of this Central Cost Allocation Plan is to arrive at an equitable distribution of common expenses reimbursable to the __________________ County Board of Health from the (Lead County) County Board of Health WIC Program based on square footage of floor space.
Shared Cost: This Central Cost Plan will include reimbursement for actual cost common to WIC.
Expenses: Expenses will be based on a percentage of the actual cost and will include the following:
Percentage of Common Space allotted to WIC (Identify Space): ____________ Total square footage of building: ________________
Common Costs: x Utilities (% of actual cost based on utility bill) x Cleaning/maintenance/supplies/paper products (% of actual cost) x Annual Electric Record Room File Maintenance (%of actual cost) x Toilet paper/paper towels (% of actual cost) x A/C & Heating Repairs/Maintenance/Insurance (% of actual cost) x Garbage (% of actual cost) x Pest control (% of actual cost) x Scale Calibration (% of actual cost) x Telephone and Fax (per Phone bill) x Use of Copy Machine/Supplies (% of actual cost) x Medical Waste (% of actual cost)
Invoices must be submitted by the 5th of the month for the previous month. Reimbursement is based on WIC funding and is not guaranteed if funding is not available.

____________________________________ Lead County Board of Health, Chairperson

___________________________________ Board of Health, Chairperson

___________________________________ District Health Director

AD-95

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-14

Financial Reviews
A. Introduction
The Department of Community Health (DCH), Office of Audits, will conduct on-site Financial Reviews every two (2) years at each of the eighteen Public Health Districts and two contract agencies for the purpose of reviewing local WIC Financial Management. The purposes of the Financial Review are to determine the appropriateness of the WIC Grant expenditures, to reconcile the District and/or local agency (county) WIC allocations and to examine the intra/inter contracts of WIC funds to the counties within the District. The Districts that were not selected for review will have a follow-up visit to ensure that corrections stated in their Corrective Action Plans (CAP) were implemented.
B. District Selection
1. District Site
Every two (2) years, fifty percent (50%) of the Districts are selected by Office of Audits with concurrence from the Georgia WIC Office for financial review.
a. The lead county in each District will always be reviewed during each financial site visit. In addition to the lead county three (3) counties within the District will also be reviewed. These counties will be reviewed to ensure that the intra/inter WIC contract requirements are being met, financial accountability of WIC funds is maintained and that all capital equipment is managed in accordance with DHR requirements for equipment accountability.
b. Counties that have not been reviewed for at least four years may be selected in place of randomly selected counties to ensure regular reviews of all counties within the district.
C. Pre-Review Activities
Prior to the on-site visit, the Office of Audits' staff will review district reports and files in the Georgia State WIC office. The Public Health District Administration will be contacted regarding materials that must be available for the on-site review.
D. Financial Review Schedule
A schedule of on-site financial reviews will be developed and coordinated by the DCH, Office of Audits and the WIC Program prior to the beginning of each Federal Fiscal Year (FFY). A statewide schedule containing the dates of each financial review will be sent to all Public Health Districts.

AD-96

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-14 (cont'd)

II. FINANCIAL TIMEFRAMES The financial review process will be conducted within the following timeframes:

ACTIVITY
Notification of intent to conduct a review. Financial Review and mutually agreed review date.
Financial Review

TIMEFRAME 20 days prior to the scheduled date As Needed

Auditors will submit the Final Review Report to the Georgia WIC Program

Within 10 days of Exit Conference

The Georgia WIC Program submits to the local agency a copy of the Financial Review. The Georgia WIC Program Financial Review Conference calls with the agency that was reviewed.

Within 20 days of Exit Conference

The local agency submits Corrective Action Plan to Georgia WIC Program

Within 30 days of Exit Conference

Georgia WIC Program submits to DCH's Office of Audits Correction Action plan with recommendation.
DCH's Office of Audits disposes of review findings. If findings are monetary, execute letterwithholding funds from agency. Close
Financial Review

Within 40 days of Exit Conference Within 60 days of Exit Conference

AD-97

GA WIC 2010 PROCEDURES MANUAL

Attachment AD-15

LOCAL AGENCY NSA FUNDING ALLOCATON
The current Nutrition Services Administration (NSA) funding formula allows growth Districts to receive their fair share of funding on the front-end. The combined caseload target is based on the current five (5) months participation closeout October-February and one month March (30 day) and the projected availability of federal food funds.
1. Caseload targets are assigned using two (2) factors.
a. Local agencies that meet or exceed caseload targets using the current federal
fiscal year five-month closeout and one month (30 day) will be assigned a new target using the highest one-month participation.
b. Local agencies that do not meet caseload targets using the current federal fiscal
year five-month closeout and one month (30 day) will be assigned a six-month average caseload target.
PROGRAM PARTICIPATION
The definition of a participant is listed below:
Participant: Participants means pregnant women, breastfeeding women, postpartum women, infants and children who are receiving supplemental foods or food instruments under the program and the breastfed infants of participant breastfeeding women. A Participant is a client who has been issued at least one voucher during the reporting month. The exclusive breastfed infant is issued a voucher message but no formula is issued.
PARTICIPANT COST ADJUSTMENT
Participant Cost Adjustment will be allocated in the next federal fiscal year to the Local Agencies that exceeded their prior year assigned caseload. This allocation will be made based upon the availability of NSA funds and State Management discretion. The Participant Cost Adjustment funding formula is as follows:
a. Number of participant that exceeded caseload.
b. Prior Federal Fiscal year funding rate per participant or participant times
funding rate times 12 months, equals Participant Cost Adjustment.

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GA WIC 2010 PROCEDURES MANUAL

Vendor Management

TABLE OF CONTENTS

Page

I.

Number and Distribution of Authorized Vendors ...........................................VM-1

II.

Vendor Application Periods.................................................................................VM-1

III. Vendor Selection and Authorization ..................................................................VM-1

IV. Peer Groups ............................................................................................................VM-2

V.

Vendor Agreements...............................................................................................VM-2

VI. Vendor Training .....................................................................................................VM-2

VII. High Risk Identification System ..........................................................................VM-3

VIII. Prohibition Against Certain Vendors - Consolidated Appropriations Act 2005.......................................................................................VM-5

IX. Vendor Cost Containment ....................................................................................VM-5

X.

Routine Monitoring ...............................................................................................VM-6

XI. Vendor Sanction System .......................................................................................VM-6

XII. Administrative Review .........................................................................................VM-6

XIII. Coordination with Supplemental Nutrition Assistance Program (SNAP) ....................................................................................................VM-6

XIV. Staff Training on Vendor Management ..............................................................VM-7

Attachments:

VM-1 Application for Vendor Authorization ..............................................................VM-8

VM-2 Selection Criteria for Vendor Authorization....................................................VM-19

VM-3 Georgia WIC Program Vendor Handbook ......................................................VM-25

VM-4 WIC Non-Corporate Vendor Agreement (3 Year) ..........................................VM-56

VM-5 WIC Corporate Vendor Agreement (3 Year) ...................................................VM-71

VM-6 Corporate Attachment Form ..............................................................................VM-85

GA WIC 2010 PROCEDURES MANUAL

Vendor Management

VM-7 Vendor Training Checklist..................................................................................VM-89 VM-8 Corporate Vendor Training Checklist...............................................................VM-90 VM-9 WIC Incident/Complaint Form.........................................................................VM-91 VM-10 Vendor Review Form ..........................................................................................VM-92 VM-11 Vendor Violation Notification............................................................................VM-96

GA WIC 2010 PROCEDURES MANUAL

Vendor Management

I. NUMBER AND DISTRIBUTION OF AUTHORIZED VENDORS
The Georgia WIC Program does not use limiting criteria to limit the number of vendors it authorizes. Any legitimate retailer, pharmacy or military commissary within Georgia and no greater than 10 miles outside of the Georgia border may apply to become an authorized vendor.
II. VENDOR APPLICATION PERIODS
Applications are accepted year round on an ongoing basis, except between August 1st and September 30th of each year. However, applications will be accepted and processed during this time in cases of inadequate participant access, which is the absence of an authorized WIC vendor within 10 miles of the applicant. (See attachment VM-1, Application for Vendor Authorization).
III. VENDOR SELECTION AND AUTHORIZATION
A. Selection Criteria
All applicants must meet the established criteria to become and maintain WIC program authorization. (See attachment VM-2, Selection Criteria for Vendor Authorization). When a potential vendor applicant requests an application, the vendor is directed to the Georgia WIC Vendor Management website at http://health.state.ga.us/programs/wic/vendorinfo.asp to retrieve the application packet, which includes the selection criteria for vendor authorization.
B. On Site Visit and Authorization
On-site visits are conducted on each vendor applicant prior to authorization to verify the information that is received during the application process, including minimum variety and quantity of WIC approved foods as well as the current shelf price. If a vendor does not have the correct quantity of approved foods on hand at the time of the pre-approval visit, the application will be denied for a period of ninety days.
When a vendor meets all authorization criteria and has received interactive training, an agreement is signed by the state agency official
VM-1

GA WIC 2010 PROCEDURES MANUAL

Vendor Management

and mailed to the vendor or to the corporate vendor's authorized representative.
Vendors are required to submit food sales information within six months of becoming an authorized WIC vendor.

IV. PEER GROUPS
Authorized vendors are classified into eight different peer groups depending on square footage of the store and/or the type of business; with the exception of Peer group 8, which is determined by food sales. (See attachment VM-3, Georgia WIC Program Vendor Handbook-Vendor authorization).

V. VENDOR AGREEMENTS
The Georgia WIC Program enters into three (3) year agreements with food retailers, pharmacies and military commissaries. (See attachments VM-4 and VM-5)
Food retailers with the same federal employment identification number and a corporate home office or a single owner business entity that serves as a parent company may sign one single agreement. This vendor is classified as a corporate vendor and must submit a list of all the stores in the chain on a corporate attachment form. This form becomes a legal addendum to the Agreement. (See attachment VM-6, Corporate Attachment Form). If one store in the chain violates the program and is disqualified, the remaining stores are not affected.
VI. VENDOR TRAINING
Vendors are provided authorization training sessions prior to authorization in an interactive format. The training sessions are conducted by the State Agency with non corporate vendor and by the corporate representative for vendors who are classified as corporate vendors. At the end of the three year agreement period, authorization training is once again provided to vendors who are re-applying.
Annual training is provided once every year using a variety of formats, (i.e. newsletters). Vendors who have received authorization training must sign certain forms as documentation. (See Attachment VM-3, Georgia WIC Program Vendor Handbook, Vendor Training; Attachment VM-7, Vendor Training Checklist and Attachment VM-8, Corporate Vendor Training Checklist).

VM-2

GA WIC 2010 PROCEDURES MANUAL

Vendor Management

VII. HIGH RISK IDENTIFICATION SYSTEMS
A. VENDOR COMPLAINTS
Vendors and participants are given a toll free customer service hotline that can be used to report complaints/incidents or make inquiries at 1-866-8145468. The participant may also contact their local WIC clinic to voice their complaint/incident. The local agency must complete a complaint/ incident form (See Attachment VM-9, Complaint Form) and begin the resolution process on all complaints from a WIC participant about a vendor. Once a complaint/incident is resolved at the local level, the form should be sent to the State for additional follow through, i.e. covert or overt visit, warning letters and entry into the vendor's record.
Resolution, at the state level, will be initiated within 24 hours of receipt. The local agency will receive notification regarding how and when the complaint/incident was resolved.
A vendor may be investigated when a complaint/incident appears to be a sanctionable offense.
B. IDENTIFYING HIGH-RISK VENDORS
Programmatic reports, including but not limited to the Vendor Profile report, are used to identify high risk vendors. The indicators listed on the Profile are: A) Small Amount of Price Variance, B) Large percent of food instruments redeemed at the same price, H) Vendor has large percent of total area redemption, M) Large percent of participants outside vendor area. To keep vendors apprised of their level of risk, the Vendor Profile is mailed to each active vendor annually.
Complaints and incidents that are reported to the WIC Program about vendors also place them in a high risk category and may lead to a covert investigation of that vendor.
C. NOTIFICATION OF VENDOR VIOLATIONS
During an investigation, if a violation is found, which requires a pattern, the vendor may receive a courtesy notice informing them of the violation. Vouchers received during the covert investigation must be cashed in order to qualify for the courtesy notice of any violation. Vendors who receive notices will be given an opportunity to correct the behavior causing the

VM-3

GA WIC 2010 PROCEDURES MANUAL

Vendor Management

violation, including training of any personnel involved in WIC transactions. The courtesy notice may include sanctions for violations that occurred which do not require a pattern (see Categories I, II, III under Sanctions). The vendor will be notified if a subsequent violation occurs and will be sanctioned accordingly. Effective October 1, 2004, during a covert compliance investigation, the Georgia WIC Program (GWP) is required to notify the vendor of an initial violation, for violations requiring a pattern of occurrences in order to impose a sanction, prior to documenting another violation, unless the GWP determines that notifying the vendor would compromise an investigation. Therefore, the GWP will send the vendor a written notice of an initial violation, during a covert compliance investigation for which a pattern of violations must be established in order to impose a sanction, except when conditions 1 through 8 listed below exist.
1. Your vendor status is considered high-risk consistent with Section 246.12(j) (3) of the Special Supplemental Nutrition Program for WIC Program federal regulations.
2. Violation(s) outlined in category VI, and category VII of the Georgia WIC Vendor Sanction System for which no pattern is required.
3. The WIC Program became aware of violations taking place during the course of an on-going investigation, during which time other vendors were found to be in violation of the WIC Program regulations, prompting further investigation.
4. WIC program received complaint(s) against vendor.
5. WIC investigator's identity may be in jeopardy.
6. Threatening conduct or security factors that may occur during the course of a covert/compliance investigation.
7. Covert sting operation by WIC, or in conjunction with other local, state or federal agencies.
8. More than one violation occurred during the initial compliance visit.
Vendors will receive notification of all results including violations after the investigation is considered closed by the WIC Program representatives.
When notices of violations are not sent to a vendor, Attachment VM-13 will be placed in the vendor's file.

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GA WIC 2010 PROCEDURES MANUAL

Vendor Management

VIII. PROHIBITION AGAINST CERTAIN VENDORS - CONSOLIDATED APPROPRIATIONS ACT 2005
A new for profit vendor will not be authorized if that vendor is expected to derive more than 50 percent of its annual food sales revenue from WIC food instruments, unless that vendor is necessary to assure participant access to program benefits. Participant access is assured by the presence of an authorized WIC vendor within 10 miles of the vendor applicant. This includes a new store location for any ownership entity that currently has a WIC authorized store, as well as an entirely new vendor applicant. This provision does not apply to the reauthorization of a current store location operated by a currently authorized vendor. All vendors are required to submit food sales data upon request in order to monitor compliance with the above 50 percent criterion. If it is subsequently determined that a vendor does not meet the above 50 percent criterion, they will be re-classified into Peer Group 8.

IX. VENDOR COST CONTAINMENT
Vendor Cost Containment is intended to assist state agencies in achieving compliance with section 17(h)(11) of the Child Nutrition Act of 1966 (CNA), as amended by the Child Nutrition and WIC Reauthorization Act of 2004 (Public Law 108-265).
The new requirements underscore the State agency's responsibility to ensure that the program pays all vendors competitive prices for supplemental foods. The State WIC Program implemented a cost containment plan to identify and manage vendors who derive more than 50 percent of their annual food revenue from WIC food instruments.
By June 30th of each year the State WIC Program will assess each vendor as to if they derive more than 50 percent of their food revenue from WIC food instruments annually and new vendors six months after enrollment.
Effective November 2008, the State WIC Program utilizes a methodology that uses redemption data to determine the maximum allowable reimbursement levels (MARLS) for food instruments.
Effective November 2008, the State WIC Program implemented new food instruments and packages for some of the special formulas with corresponding MARLS.

VM-5

GA WIC 2010 PROCEDURES MANUAL

Vendor Management

X. ROUTINE MONITORING
On site, overt monitoring is performed on a minimum of five percent of the total active vendors statewide on an annual basis using a standardized monitoring instrument (See Attachment VM-10, Vendor Review Form). Vendors statewide (except commissaries and pharmacies) are selected for routine monitoring visits based on : 1) complaints/incidents regarding a specific vendor; 2) a current list of vendors that have been on the program the longest and have not received a routine monitoring visit prior to FY 2004 and no later than 2007; 3) requests from investigators as a result of their findings during a covert visit. Vendors receive written notification of the results and copies are sent to the vendor's corporate office, when applicable. (See Attachment VM-3, Georgia WIC Program Vendor Handbook, Overt Monitoring).

XI. VENDOR SANCTION SYSTEM
When any authorized vendor is found to be in violation of federal regulations and/or state policies and procedures, the vendor will be assessed a sanction consistent with the severity and nature of the violation. Sanctions may include disqualification or a civil money penalty. (See attachment VM-3, Georgia WIC Program Vendor Handbook, Sanction System).

XII. ADMINISTRATIVE REVIEW
The Georgia WIC Program conducts full Administrative Reviews and Abbreviated Administrative Reviews. (For Administrative Review and Abbreviated Administrative Review procedures, see attachment VM-3, Georgia WIC Program Vendor Handbook, Administrative Review Procedures and Abbreviated Administrative Review Procedures).

XIII. COORDINATION WITH SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
A reciprocal agreement between the Georgia WIC Program and the Food and Nutrition Services Food Stamp Program is on file at the State Agency (See attachment VM-12, Cooperative Agreement Between the Georgia WIC Program and FNS Field Office).

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GA WIC 2010 PROCEDURES MANUAL

Vendor Management

The Georgia WIC Program's Compliance Analyses Unit routinely coordinates their investigative activities with their Food Stamp Program counterparts on high-risk WIC vendors.

XIV. STAFF TRAINING ON VENDOR MANAGEMENT
New employees receive orientation and on the job training on the following Vendor Management topics:
1. The application process (selection and authorization) 2. Vendor Training 3. Routine Monitoring 4. Compliance Investigations 5. Inventory Audits (when applicable) 6. Sanctions 7. Vendor Appeals/Administrative Reviews 8. Federal and State WIC regulations 9. High Risk Vendor Identification 10. GWIS (Georgia WIC Information System) and other internal vendor
databases such as VIPS and STARS

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GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1

GEORGIA WIC PROGRAM APPLICATION FOR VENDOR AUTHORIZATION AND INSTRUCTIONS
Please print or type legibly. Follow the attached instructions, starting on page 6, carefully. Incomplete forms and attachments will be returned unprocessed.
FOR GEORGIA WIC Program (GWP) USE ONLY

District/Unit

Vendor Number

Peer Group

Date Received in VMU Return Date

Received By Date Received

Pre-screened By Return Date

Returned By Date Received

Return Date

Date Received

Return Date

Date Received

Date Placed in bin for Pick-up Date Approved
Date Denied
Reason Denied

OAS: QAS:

Date Reviewer

Received

VM:

VD:

VM:

VD:

Date Stamp Sent Date Denial Letter Sent

Processed By

Check one

Re-Application (Enter current vendor number) _______________________

Initial Application

(New Vendor must provide food sales data within six months of authorization.)

A. Will this store participate as a corporate vendor?

Yes

No

B. Is this store expected to derive more than 50% of its annual food sales

from the sale of WIC approved foods?

Yes

No

C. Is this application submitted as a result of a change in the store's location?

Yes

No

D. Will this store sell medical formula and special medical foods only?

Yes

No

PART I - STORE IDENTIFICATION

1. Full Legal Name of Store

Full Legal Name of Corporation (if applicable)

Manager's Name

Business Telephone Number E-mail Address (Required)

-
Area Code

2. Physical Location

Street Address/Rural Route

City

State Mailing Address (If Different From Above)

Street Address/P. O. Box

City

Store Number

-

Fax Number

-

-

Area Code

County Zip +4
State

Zip + 4

3. Square Footage of Store (including storage area)

4. Food Sales Establishment License Number

5. Does this store now participate in the SNAP Program (formerly the

Yes

No

Food Stamp Program)?

Indicate the Food Stamp Authorization Number

VM-8

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

6. Type of Business - Check Only One Independent

Commissary

Chain

Pharmacy

7. Federal Employer Identification Number

or Owner's SSN

8. A. Is this store dependent upon receiving WIC Authorization before it can open for business?

B. What date did (or will) the store open for business under the applying Month owner(s)?

C. What date will the store have the required minimum inventory of Month approved WIC foods in stock?

9. A. Are you related to previous owner(s) by blood or marriage? If YES, what is the relationship?

B. Have the owner(s) ever owned a business(es) authorized by the Georgia WIC Program? If YES, list stores below. Attach additional paper if necessary.

1.
STORE NAME
2.
STORE NAME

VENODR NUMBER VENDOR NUMBER

-
Yes /
Day
/
Day
Yes
Yes

-
No /
Year
/
Year
No
No

C. Has this store ever operated under another name in Georgia or states that are 25

Yes

No

miles outside of the Georgia border?

If YES, indicate name.

PART II - STORE OWNERSHIP AND MANAGEMENT

10. Type of Ownership Check one Sole proprietorship
Partnership
Limited Liability Corporation

Privately owned corporation Publicly owned corporation Government owned Non-profit

VM-9

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

11. List the full name (NO INITIALS) of every owner with 5% or more financial interest in the company. If the type of ownership listed above is a publicly owned corporation or government owned, DO NOT complete this section. Attach additional sheets if needed. Shortened versions of a name are not acceptable.

1.
First Name

Middle Name

Last Name

Social Security Number

Date of Birth

2.
First Name
Date of Birth

Middle Name

Last Name

Social Security Number

3.
First Name

Middle Name

Last Name

Social Security Number

Date of Birth

12. Ownership History

A. Including this store, has the current owner(s), officer(s) or manager(s) ever

owned or managed a business that violated the Georgia WIC Program, receiving

a disqualification or assessment of a Civil Money Penalty?

If YES, attach an explanation identifying the person, business name, location and nature of violation.

Yes

No

B. Including this store, has the current owner(s), officer(s) or manager(s) ever owned or managed a business that violated the SNAP Program, receiving a warning letter or was withdrawn, disqualified or assessed a Civil Money Penalty?

Yes

No

If YES, attach an explanation identifying the person, business name and nature of violation.

C. Has the current owners, officers or managers ever been convicted of or had a civil judgment for fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims or obstruction of justice?

Yes

No

If YES, attach an explanation identifying the person, date and nature of violation.

13. A. Does the current owner(s), officer(s) or manager(s) currently or previously own(ed) or manage(d) a business whereby more than 50% of the total annual food sales is derived from the sale of WIC approved foods?

Yes

No

B. If YES, identify the name of the store, identification number (ID), city and state. Include stores nationwide, and Georgia.

1. Store Name City

ID State

2. Store Name City

ID State

3. Store Name City

ID State

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GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

PART III - OPERATIONS AND SALES

14. A. Were all infant formula, that will be used to redeem WIC vouchers, purchased from suppliers listed on the Approved Infant Formula Supplier list? (see www.health.state.ga.us/programs/WIC/vendorinfo.asp)

Yes

No

Note: Records of all infant formula purchases must be maintained according to the terms of the WIC Vendor Agreement, III, I.3.

B. If yes, indicate the name of the supplier, address, city and State. (Attach additional paper if necessary.)

Supplier City

Address State

Supplier City

Address State

Supplier City

Address State

15. Hours of Business Check here if opened 24 hours each day
Sunday Monday Tuesday Wednesday

Thursday Friday Saturday

16. All vendors (Pharmacy Excluded) must carry food items other than WIC Approved Foods. What percent of each item does this store carry from the following food groups? This includes dried, frozen, canned/jar, fresh, etc. The total percentage must equal 100%

A. Meats, Poultry and/or Seafoods (refrigerated) B. Dairy (milk, cheese) Eggs and/or Cereal C. Staples (i.e. Flour, Sugar, Pasta, Rice, Pudding, etc.) D. Cans, jars, Bottled Goods (i.e. Pickles, Olives, Ketchup, Mustard,
etc) E. Beverages F. Snack Foods (Chips, Cookies, Candy etc.)
Other food(s) not counted in A-F (specify) ____________

17. A. Number of Cash Registers

B. Number of Scanners

C. Can Scanners detect WIC eligible foods?

Yes

No

D. Does your store have a Point of Sale Device?

Yes

No

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GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

PART IV - INVENTORY AND PRICE LIST

Food Item

Brand Name

18. Juice

19 Cereal

20. Peas/Beans Peas/Beans

21. Peanut Butter

22.

Infant Cereal Rice

Similac Advance Early Shield 23. w/Iron
Similac Advance Early Shield w/Iron (Powder)
24. Isomil Advance w/Iron
Isomil Advance w/Iron (Powder) Whole Pasteurized 25. Milk 26. 2%, 1% or Skim Milk 27. Dry Milk

28 Cheese

29. Eggs (Large Only) 30. Fresh Fruit 31. Fresh Vegetables 32. Bread
Fish Tuna or 33. Salmon
Baby Food Fruits 34. and vegetables 35. Baby Food Meats

Size

Highest Price or On-Site

Least Expensive Price

where indicated

46-48 oz. bottle 64 oz. plastic bottle 11 to 36 oz. box 1 pound bag 14-16 oz cans 18 oz. jar

8 oz. box 13 oz. can concentrate

12.9 oz. can
13 oz. can concentrate
12.9 oz. can
1 gallon container
(Least Expensive)
1 gallon container
(Least Expensive)
Makes 3 quarts
1 pound package
(Least Expensive)
1 dozen carton
(Least Expensive)
10 pounds 10 pounds 16 oz. loaf 5-6 oz. can

P PART IV STOR
E PRIC
E LIST AND INVE NTO
RY ART IV STOR
E PRIC
E LIST AND INVE NTO RY

4 oz. jar 2.5 oz. jar

VM-12

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

Food Item

Brands (B) Types (T) Size

Item In Stock? Minimum Quantity In Stock?

36. Juice 37. Juice

2 (T)

46 oz.

Yes

No

12

Yes

No

2 (T)

64 oz.

Yes

No

12

Yes

No

38. Cereal

4 (T) 11 to 36 oz. Yes

(2 types must be Whole Grain)

No

24

Yes

No

39. Dried Peas/Beans 40. Canned Peas/Beans

2 (T) 1 lb. pkg. Yes

No

5

Yes

No

2 (T) 14-16 oz. Yes

No

18

Yes

No

41 Peanut Butter 42. Infant Cereal
(1 type must be rice)

2 (B)

18 oz.

Yes

No

6

Yes

No

2 (T)

8 oz.

Yes

No

12

Yes

No

Yes

No

Yes

No

43. Similac Advance Early Shield

1 (B)

13 oz.

Yes

No

62

Yes

No

w/Iron

44. Similac Advance Early Shield

1 (B)

Yes

No

30

Yes

No

Powder w/Iron

45. Isomil Advance w/Iron

1 (B)

13 oz.

Yes

No

31

Yes

No

46. Isomil Advance Powder w/Iron 1 (B)

Yes

No

15

Yes

No

47. Pasteurized Milk - whole

1 (B) 1 gallon

Yes

No

12

Yes

No

48. Pasteurized Milk 2%, 1% or

1 (B) 1 gallon

Yes

No

18

Yes

No

skim

50. Dry Milk non-fat

1 (B) Makes 3 qt. Yes

No 3 boxes Yes

No

51. Cheese
52. Eggs (Large Only) 53. Bread 54. Fruit 55. Vegetables 56. Fish (Tuna or Salmon)
57. Baby Food Fruits 58. Baby Food Vegetable 59. Baby Food Meat

2 (T) 1 pound

Yes

No

8

Yes

No

1 (B) 1 dozen

Yes

No

8

Yes

No

1 (B) 16 oz. loaf Yes

No

6

Yes

No

4 (T) 10 pounds Yes

No 10 lbs.

Yes

No

4 (T) 10 pounds Yes

No 10 lbs.

Yes

No

1 (T) 5-14.75 oz. Yes

No

18

Yes

No

can

2 (T)

4 oz.

Yes

No

96

Yes

No

2 (T)

4 oz.

Yes

No combined Yes

No

2 (T)

2.5 oz.

Yes

No

31

Yes

No

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GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

PART V - STATEMENTS AND CERTIFICATION

PRIVACY ACT STATEMENT The collection of this information is authorized by Part 246.12 of Federal Regulations 7CFR, Ch.11 which
governs the Special Supplemental Nutrition Program for Women, Infants and Children. It will be used to determine whether a store qualifies to participate in the WIC Program, monitor compliance with program regulations and for program management. The provision of the requested information, including the Federal Employer Identifier Number or Social Security Number, is voluntary. However, failure to provide information may result in the denial or termination of authorization to participate in the WIC Program. The purpose of collection of this information is for audit and enforcement of WIC regulations.

WARNING STATEMENT Information in this application may be verified with other agencies. The authorization of the vendor to participate in
the Georgia WIC Program can be denied or terminated if it is determined that the vendor applicant provided false statements, made false representations, or used any false writing or documentation in conjunction with this application. WIC participation can be terminated if the business violates any laws or regulations issued by Federal or State programs including the Food Stamp Program and Food Stamp Program regulations.

CERTIFICATION AND SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE
1. I have authority to apply for authorization for this store to participate in the Georgia WIC Program. 2. I will update the information on this application as required by the WIC Program. 3. I affirm that all statements made in this application are true.

SIGNATURE

(no initials)

First
PRINT NAME

Middle

(no initials)

First

Middle

DATE
Last
Last

TITLE

In accordance with Federal Law and U.S. Department of Agriculture policy, "this institution is prohibited from discriminating on the bases of race, color, national origin, sex, age, or disability." To file a complaint of discrimination, write USDA, Director, and Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SE Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Return application to: DO NOT FAX
DO NOT HAND DELIVER

Georgia WIC Program Vendor Management Unit 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303-3142 Toll free 1-866-814-5468 or 404-657-2900

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GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

Instructions for Completing the Vendor Application

Check appropriate box to indicate if application is Re-application or Initial Application. If application is a Re-application, please enter the current vendor number in the space provided.

A. Answer yes or no if your store will participate as a corporate vendor.

B. Answer yes or no if your store expects to derive more than 50% of its annual food sales from the sale of WIC approved foods.

C. Answer yes or no if application submitted as a result of a change in store's location?

D. Answer yes or no if you will be selling medical formula (formula other than the contract formula) and special medical foods only.

PART I - STORE IDENTIFICATION

1. FULL LEGAL NAME OF STORE. Enter the name of the store. Include the store number, if applicable. Corporate Vendors with two or more locations, enter CA (Corporate Attachment form). FULL LEGAL NAME OF CORPORATION (if applicable). Enter the legal name of the Corporation under which the store(s) is licensed. Include the name for public-owned and private-owned corporations. If the corporation has a division or department that is dedicated to handling WIC issues, enter the name of the division or department after the name. MANAGER'S NAME. Enter the name of the person responsible for this store location. Corporate Vendors, enter CA. BUSINESS TELEPHONE NUMBER. Enter the main telephone number located at the store. DO NOT LIST CELLULAR TELEPHONE NUMBERS. Corporate Vendors enter the main telephone number for the corporation. If the corporation has a division or department dedicated to handling WIC issues, enter the number of the division or department. FAX NUMBER. Enter the fax number for the store entered above. Corporate vendors enter the main fax number for the corporation. If the corporation has a division or department dedicated to handling WIC issues, enter the fax number of the division or department. E-MAIL ADDRESS. Enter the e-mail address for the manager listed above. Corporate Vendors enter the main e-mail for the company.

2

Physical Location

STREET ADDRESS. Enter the street name and number of the store.

Corporate vendors enter CA. DO NOT enter a Post Office Box here.

CITY. Enter the name of the city.

COUNTY. Enter the county where the business is located.

STATE. Enter the state in which the business is located.

ZIP+4. Enter the postal code + the four digit locator code.

Mailing Address STREET ADDRESS. Enter the street name and number for the store where mail is to be delivered for the location above. A Post Office Box may be entered in this space. Corporate vendors enter the street address of the home office of the corporation. If the corporation has a division or department dedicated to handling WIC issues, include the floor/suite of the department or division. CITY. Enter the name of the city. Corporate vendors enter the city of the home office. STATE. Enter the name of the state. Corporate vendors enter the state of the home office. ZIP+4. Enter the postal code + the four digit locator code.

3. SQUARE FOOTAGE. Enter the store's total square footage including storage area. Corporate vendors enter CA.

4. FOOD SALES ESTABLISHMENT LICENSE NUMBER. Enter the Food Sales Establishment License Number issued in the current owner's name. The owner's name listed on the application must match

VM-15

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

the name on the license. Some Pharmacies and military commissaries may not be required to have this license and should enter Not Applicable (N/A). Corporate vendors enter CA.
5. Answer yes or no. Does this store participate in the Supplement Nutrition Assistance Program (SNAP: formerly the Food Stamp Program)? If yes, enter the authorization number for this location. Corporate vendors should answer this question based on the answer that applies to the majority of the stores.
6. TYPE OF BUSINESS. Check the box that best fits the type of business for your store or corporation. Independent. A store independently owned by a person or group. Chain. A business entity that has multiple locations throughout one or more states. Commissary. A military outlet providing goods and services for military personnel and their families. Commissaries receive exemptions through the 1983 Memorandum of Understanding between the Food and Nutrition Service and the United States Department of Defense. Pharmacy. A "drug" store applying to redeem exempt and/or special infant formulas, including medical foods. No contract formula or other standard WIC approved food sales are allowed for pharmacies
7. FEDERAL EMPLOYER IDENTIFICATION NUMBER. Enter the Federal Employer Identification Number (FEIN) assigned to the store by the Internal Revenue Service. If the owner is a sole proprietor and does not have a FEIN, enter the owner's Social Security Number (SSN). If a FEIN is entered, DO NOT enter the SSN. Corporate Vendors, enter CA.
8. Answer the question regarding minimum inventory and opening date A. Answer yes or no whether this store is dependent upon WIC authorization before it can open for business. B. OPENING DATE. Enter the specific month, day and year that the store will open under the applying owner(s). If the store is currently open for business at the time of application, enter the official date the store opened or the date a change of ownership became effective. Enter Not Applicable (N/A) if the store is currently authorized as a WIC vendor and is re-applying for authorization. C. MINIMUM INVENTORY. Enter the specific month, day and year that ALL required quantity and variety of WIC approved foods (including perishables) will be in stock and ready for inspection. See Selection Criteria for Vendor Authorization for exact quantities. Enter Not Applicable (N/A) if the store is currently authorized as a WIC vendor and is re-applying for authorization.
9. Answer the questions regarding ownership history. A. RELATION TO OWNER. Check yes or no to indicate if you are related to the previous owner by blood or marriage. If yes, indicate the relationship. B. OTHER WIC AUTHORIZED STORES. Check yes or no to indicate if any owner(s) also own other WIC authorized stores. If the owner(s) listed in question 11 have additional stores that are WIC authorized, list the name of the store in the space provided. Include the WIC vendor number. Attach additional paper if necessary. Corporate Vendors enter CA. C. OPERATION UNDER ANOTHER NAME. Check yes or no to indicate if the store has ever operated under another name. If yes, indicate the name.
Part II STORE OWNERSHIP AND MANAGEMENT
10. TYPE OF OWNERSHIP. Check the one type that closely represents your business. Sole proprietorship. A business owned by a single individual. Partnership. A business owned by two or more individuals. Limited Liability Company (LLC). A business combining both corporations and partnerships in that the business is required to register with the Secretary of State but do not have the same filing and record maintenance as a corporation. Privately owned corporation. For purposes of this application, a privately owned corporation is one which has shares or stock that are not traded on a stock exchange nor available for purchase by the general public. Publicly owned corporation. For purposes of this application, a publicly owned corporation is one which has shares or stock that are traded on a stock exchange and are available for purchase by the general public.
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Attachment VM-1 (cont'd)

Government owned entity. A business entity that may include commissaries, pharmacies or clinics owned and operated by county, state or federal government agencies. Nonprofit. A business entity that has been granted nonprofit, tax exempt status from the Internal Revenue Service.
11. NAMES OF OWNERS. Enter the information for all owners with a 5% or more interest in the store. List the full name (first, middle and last) for each owner. Also list the social security number and the date of birth for each owner. Attach additional paper if necessary. Initials or shortened versions of a name are not acceptable. Do not complete if the store is government owned or publicly owned.
12. OWNERSHIP HISTORY A. PREVIOUS GEORGIA WIC VIOLATIONS. Check yes or no to indicate if the current owners, officers or managers have ever violated Georgia WIC Program by receiving a warning, probation, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, the person, store name and address, and nature of the violation. B. SNAP (Supplemental Nutrition Assistant Program formerly Food Stamps) VIOLATIONS. Check yes or no to indicate if the current owners, officers or managers have ever violated the SNAP Program by receiving a warning, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, person, store name and address, and nature of the violation.
C. CONVICTIONS/JUDGEMENTS. Check yes or no to indicate if the owner, current officers, or
manager ever had a civil judgment involving fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims or obstruction of justice. If yes, attach an explanation identifying the person,
date and nature of the violation.
13. A. Answer yes or no if there is a store(s) that derives more than 50% of its total annual food sales from WIC voucher transactions.
B. If yes, enter the name, ID number assigned by the authorizing WIC agency, city and state.
PART III OPERATIONS AND SALES
14. A. Answer yes or no whether all infant formula purchases, which will be used with WIC vouchers, were purchased from the approved list. (This excludes medical foods and specialized infant formula).
B. If yes, enter the suppliers name, address, city and state.
15. HOURS OF BUSINESS. Enter the hours the store is actually open for business each day. Corporate vendors, enter the hours that the majority of the stores are actually open for business.
16. Enter the percentage of what you carry next to each category of food. Percentage totals must equal 100%. If your store is new and/or there is no history of food sales, enter the percentage of foods in each category you anticipate carrying.
17. A. NUMBER OF CASH REGISTERS. Enter number of cash registers in the store. Corporate vendors, enter the average number of cash registers per store. Corporate vendors must enter the exact number of cash registers per store on the Corporate Attachment Form.

B. NUMBER OF SCANNERS. Enter the number of scanners in the store. Corporate vendors, enter the average number of scanners per store. Corporate vendors must enter the exact number of scanners per store on the Corporate Attachment Form.

C. OPTICAL SCANNERS. Check yes or no if the scanner(s) can detect WIC eligible products.

D. POINT OF SALE (POS) DEVICES. Check yes or no if there is a Point of Sale device at each register. This is the machine used to swipe credit or debit cards at each checkout.

PART IV STORE PRICE LIST AND INVENTORY

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Attachment VM-1 (cont'd)

18-35. Enter the brand name and highest price or least expensive price, of each approved WIC food item in the sizes listed. Use the current WIC Approved Foods List to complete this section. Do not complete the shaded area.
Corporate Vendors: List the brand and highest price or least expensive price that exists among all the stores in the chain.
Pharmacy Vendors: Do not complete Items 18-33. Instead, complete the enclosed Pharmacy Price List.
36-59. Check yes or no if the quantity of brands or types is currently in stock in the size indicated. Check yes or no if the required minimum quantity of approved WIC foods are in your current inventory in the quantities indicated. Corporate vendors: answer yes or no for all existing stores in the chain. Pharmacy Vendors: Enter N/A (non applicable)
Review the Privacy Act Statement, Warning Statement and Certification. An owner or authorized representative must sign, print name and date the application. Initials or a shortened version of a name is not acceptable.

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Attachment VM-2

Selection Criteria for Vendor Authorization
All applicants must meet the following criteria at the time of application and sustain the criteria throughout the entire agreement period. The Georgia WIC Program may deny the application or terminate the vendor agreement if it is determined that the applicant provided false information in conjunction with the application.
Applications will not be accepted "between August 1 September 30" of each year.
Changes mandated by USDA may occur to the selection criteria after an application has been submitted. When this happens, applicants will be notified regarding the changes, and must comply with the changes in order to become authorized. If this application is denied for any of the criteria below, the application will be denied for a ninety (90) day period. A store must not accept WIC vouchers until it is authorized by the Georgia WIC Program. If it is determined that a store is in violation of this regulation, the application will be denied for a one year period.
1. Additional Required Information. All requested information must be provided, upon request, in order to process the application. This includes but is not limited to the Bill of Sale, Articles of Incorporation, Driver's License or State issued ID card, Social Security card, food sales, etc.
2. Minimum Inventory of WIC Approved Foods. (See chart below.) Stores are required to stock and maintain daily the minimum inventory of approved WIC foods. A. The inventory must be in the store or the store's stockroom. B. Expired foods do not count towards minimum inventory. (Note: All WIC approved foods currently in stock, including the minimum amounts, must be within the expiration dates at the time of application). C. Pharmacies are exempt from minimum inventory requirements. D. Commissaries are exempt from the minimum requirement under the 1983 Memorandum of Understanding between the United States Department of Agriculture, Food and Nutrition Service and the United States Department of Defense.

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GA WIC 2010 PROCEDURES MANUAL

Food Item

Georgia WIC Program

Minimum Inventory Requirements

Effective October 1 , 2009

Types/Brands

Size

MILK Least Expensive Brand of
type selected/allowed

Whole Milk Fat free/Skim, Low-fat (1%),
Reduced Fat (2%) Milk Dry powdered milk

Gallon Gallons
Makes 3 quarts

CHEESE Least Expensive Brand of
type selected/allowed

One pound package

16 oz. (1 pound)

EGGS Least Expensive Brand

Grade A Large

1 Dozen carton

PEANUT BUTTER

Any brand Creamy, Crunchy, or Extra Crunchy (Regular or Low-
salt)

16-18 oz

BEANS / PEAS / LENTILS
JUICE WHOLE GRAIN-
BREAD CEREAL Whole Grain
FISH Least Expensive of type
selected
INFANT FORMULA

Dried Beans / Peas / Lentils
Canned Beans / Peas / Lentils Ready to Serve Container Ready to Serve Container
Whole Grain Bread
WIC Approved Cereal Brands and Types
(see WIC Approved Foods List) Tuna
Pink Salmon Milk Based Similac Advance Early Shield Soy Based Similac Isomil Advance Milk Based Similac Advance Early Shield Soy Based Similac Isomil Advance

1 pound packages 14 to 16 oz cans
46-48 oz 64 oz 16 oz loaf
11-36 oz 5 oz Can 7.5 oz or 14.75 oz
13 oz Concentrate
12.9 oz Powder

INFANT CEREAL

Dry cereal in

8 oz box

INFANT FRUIT & VEGETABLES INFANT MEATS
FRUITS &VEGETABLES

Fruit and /or Vegetable
Meats in Gravy Fruits
Vegetables

4 oz Jars
2.5 oz Jars 10 Pounds Combined 10 Pounds Combined

Attachment VM2 (cont'd)

Minimum Inventory ;

12 Gallons



18 Gallons



(Can be Combined)

3 Boxes



8 1 lb packages



8 1 Dozen



6 - 16-18 oz Containers



5 Packages - 2 types
18 Cans - 2 types

12 Containers - 2 types



12 Containers - 2 types



6 Loaves



24 Boxes - 4 types, 2 must be whole grain



18 Cans Combined



Milk Based - 62 Cans



Soy Based - 31 Cans

Milk Based - 30 Cans



Soy Based - 20 Cans

12 Boxes - 2 types, 1 must be rice



96 Jars Combined



31 Meat



4 types fresh



4 types fresh



Non-WIC Inventory Requirement

Food Item

Type

Meats, Poultry and/or Seafood (refrigerated)

NON-WIC



Breads and Cereal Products

NON-WIC



Dairy (i.e. milk, cheese, ice cream, yogurt, etc.)

NON-WIC



Staples (i.e. flour, sugar, pasta, pudding, etc.)

NON-WIC



Cans, Jars, Bottled Goods (i.e. mayo, ketchup, relish, etc.)

NON-WIC



Beverages (i.e. soda, water, powdered drinks, etc.)

NON-WIC



Snack Foods (i.e. chips, cookies, crackers, candy, etc.)

NON-WIC



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GA WIC 2010 PROCEDURES MANUAL
Selection Criteria

Attachment VM2 (cont'd)
Page 3

YOU MUST PROVIDE ALL OF THE FOLLOWING OR YOUR APPLICATION WILL BE DENIED

3. All applicants will receive an on-site pre-approval visit from State representatives to verify the information listed on the application and items A & B above. Corporate vendors adding new locations to their existing corporate agreement whose stores will fall into peer groups 3, 4, 6 or7 will not receive a pre-approval visit. Vendors falling into these categories will need only to submit the corporate attachment form and corporate training checklist for each additional store being added to the current agreement. PRE-APPROVAL VISITS WILL NOT BE CONDUCTED UNTIL A VENDOR HAS ATTENDED TRAINING AND PASSED THE EVALUATION WITH A SCORE OF 80 OR ABOVE. The Georgia WIC Program will conduct the visit based on the date you stated you will have the required minimum inventory of WIC approved foods in stock (question 8C on the application). If you see that you will not have the inventory by the date stated on your application, please contact our office IMMEDIATELY to prevent denial of your application by calling 1-866814-5468 or (404) 657-2900.
4. Provide Adequate Access for Participants. The store must be open for business at least 8 hours per day, six days per week. (Exceptions may be granted at the State's discretion.)
5. Provide Suitable Store Location. There must be a store sign to identify the store with the name of the business clearly marked. The store must not be located inside of another facility that is not food retail in nature. This includes, but is not limited to a suite on the upper floors of an office building, inside a community center, daycare, floral shop, etc.
6. Compliance With the Georgia Department of Agriculture. Each store must have a valid Retail Food Sales Establishment License in the current owner's name. Pharmacies and military commissaries are exempt from this requirement. Stores in bordering states must have a comparable license.
7. Compatible Prices With Similar Stores. The prices listed on the application will be compared with the State's pre-established baseline prices. An applicant, whose prices exceed the established price, for selected food packages and/or voucher codes, will not be authorized.
8. Compliance With the Supplemental Nutrition Assistance Program (SNAP) Regulations. Effective December 1, 2009, all vendors must be licensed by the United States Department of Agriculture Food Nutrition Service as a Supplemental Nutrition Assistance Program or SNAP retail provider (formally the Food Stamp Program). Unless necessary to ensure adequate participant access, the Georgia WIC Program will not authorize an applicant that is currently disqualified from the SNAP Program or that has been assessed a civil money penalty (CMP) for hardship and the disqualification period has not expired.
9. Compliance With Georgia WIC Program Policies and Procedures. Sanctions - any sanction(s) that are in the vendor's record at the time of re-authorization will remain on the vendor's record. Prior year's sanctions may result in denial of application and/or additional sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.
A. Violations - Pending and/or potential violations, that exists at the time of re-authorization will accrue and will result in sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.
B. If it is determined that an applicant is attempting to circumvent a period of disqualification from the Georgia WIC Program, the application will be denied until the disqualification period has expired.
10. Business Integrity. Unless necessary to ensure adequate participant access, the Georgia WIC Program will not authorize an applicant that does not meet the business integrity criteria based on facts already known and information provided on the application. This includes but is not limited to the following: A. Criminal conviction or civil judgments during the past six years among the applicant's owner's, officer(s) or manager(s) for any activity indicating a lack of business integrity such as fraud, antitrust violations embezzlement, theft, forgery bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims and obstruction of justice. B. Official records of removal from other federal, state or local programs.
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GA WIC 2010 PROCEDURES MANUAL
Selection Criteria

Attachment VM2 (cont'd)
Page 4

C. The applicant vendor shall not acquire a store location or entity that was sold or assigned as a result of transferring the ownership of a disqualified vendor's partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. If it is later determined that failure to abide by this provision is evident, the vendor may be subject to civil liability, fines, and penalties.

11. 50% Criterion. A new for profit vendor will not be authorized if that vendor is expected to derive more than 50 percent of its annual food sales revenue from WIC food instruments, unless that vendor is necessary to assure participant access to program benefits. Participant access is assured by the presence of an authorized WIC vendor within 10 miles of the vendor applicant. This includes a new store location for any ownership entity that currently has a WIC authorized store, as well as an entirely new vendor applicant. YOU MUST CARRY OTHER FOODS OUTSIDE OF THE WIC MINIMUM INVENTORY AND WIC APPROVED FOODS. This provision also applies to the reauthorization of a current store location operated by a currently authorized vendor. All vendors are required to submit food sales data upon request in order to monitor compliance with the above 50 percent criterion. If it is subsequently determined that a vendor does not meet the above 50 percent criterion, they will be re-classified into Peer Group 8 Above 50% Vendors. All vendors must carry the subsequent amount of non-WIC food items in ALL of the following categories in order to be considered for authorization:
A. Meats, Poultry and/or Seafood (refrigerated) B. Breads and Cereal Products C. Dairy (milk, cheese, yogurt, ice cream etc.) D. Staples (i.e. flour, sugar, pasta, rice, pudding, etc.) E.. Cans, Jar, Bottled Goods (i.e. tomatoes, mayo, ketchup etc.) F.. Beverages (i.e. soda, water, powdered drinks etc.) G. Snack Foods (i.e. chips, crackers, cookies, candy, etc.)
There will be an onsite inventory audit of all the above items and any information obtained will be assessed prior to a decision.
12. Infant Formula Suppliers. All vendor applicants are required to purchase infant formula, which will be redeemed for WIC vouchers, solely from a list of suppliers selected and approved by the Georgia WIC Program. The list can be obtained via the Internet at www.health.state.ga.us/programs/WIC/vendorinfo.asp, (click on Approved Infant Formula Suppliers). Acrobat Reader must be installed on the computer to view the list. If a supplier is not listed, a vendor is required to call 866-814-5468 or 404-657-2900, to inquire about adding them to the list. After the vendor has requested the addition, the vendor must ensure that the Georgia WIC Program has authorized the supplier, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained for four years or until investigations are adjudicated when applicable.
13. WIC Acronym and Logo. The WIC authorized vendor is not permitted to use the WIC acronym, or the WIC logo including close facsimiles thereof in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program, including wording such as "WIC Only". The state agency will make a determination and notify the vendor if misuse is determined. If a vendor fails to discontinue the use of the WIC acronym or the WIC logo including close facsimiles thereof, in total or in part, after misuse is determined, the application will be denied.

Denial of Vendor Authorization or Re-Authorization
During the authorization or the re-Authorization process, vendors may be denied for any of the following reasons:
Application Submitted Outside Timeframe The applicant submitted the initial application between the dates of August 1 and September 30. During this time period, new applications are not accepted or processed.

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GA WIC 2010 PROCEDURES MANUAL
Selection Criteria

Attachment VM2 (cont'd)
Page 5

Requested Information not provided The applicant did not provide the necessary documentation as requested. Insufficient WIC Inventory The applicant did not have the minimum variety and/or quantity of WIC approved supplemental foods required during the on-site pre-approval visit. Inadequate Access The store is not open 8 hours per day, six days per week. Prices Exceed Maximum Allowable Reimbursement Level (MARL) Allowed Shelf prices exceeded the Average Redemption currently allowed on Georgia WIC Program vouchers during the on-site pre-approval visit. SNAP Disqualification or Civil Money Penalty Assessment Applicant has been disqualified from the Supplemental Nutrition Assistance Program or has been assessed a civil money penalty for hardship and the disqualification period that would otherwise have been imposed has not expired. History of Georgia WIC Sanctions Applicant has been disqualified and all administrative appeals have been exhausted. Business Integrity Applicant has a conviction or civil judgment Applicant provided false statements, false representations, or used false writing or documentation Applicant is expected to derive more than 50% of it's annual food revenue from WIC foods. Ownership has been linked to a current 50% vendor Owner related by blood, marriage, partners, members, owners, officers, directors, employees, heirs or assigns purchased store to circumvent a sanction or disqualification of another vendor. Use of the Acronym or Logo Applicant used the WIC Acronym or Logo as a part of their name or advertisments.

Requests for an Administrative Review
The validity or appropriateness of the Georgia WIC Program's selection criteria is not subject to administrative review. An applicant may request an administrative review if the application is denied for the following reasons:
1) Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods or the determination that the vendor is attempting to circumvent a sanction.
2) Disqualification. 3) Imposition of a civil money penalty in lieu of disqualification. 4) Denial of authorization based on the vendor selection criteria for business integrity or for a current SNAP
Program disqualification or civil money penalty for hardship. 5) Denial of authorization because a vendor submitted its application outside the established timeframes. 6) Disqualification based on a trafficking conviction. 7) Disqualification based on the imposition of a SNAP Program civil money penalty for hardship in lieu of
disqualification. 8) Denial of authorization based on the determination that an applicant is expected to meet the >50%
Criterion. 9) Denial of authorization based on applicant purchasing infant formula from an unapproved infant formula
supplier, which was not listed on the Approved Infant Formula list.
A request for review must be submitted in writing within twenty-one (21) days of the date of the denial notice. Submit the request to:
Vendor Management Unit Administrative Review Request Georgia WIC Program 2 Peachtree Street NW, Suite 10-476 Atlanta, Georgia 30303-3142
The procedures for an administrative review include the following: 1. Written notification of the adverse action. 2. The opportunity to appeal the action.
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GA WIC 2010 PROCEDURES MANUAL

Attachment VM2 (cont'd)

3. Adequate advance notice of the time and place of the administrative review.

4. The opportunity to present a case and at least one opportunity to reschedule.

5. The opportunity to cross-examine adverse witnesses (When necessary to protect the identity of WIC

Program investigators, such examinations may be conducted behind a protective screen or other

device).

6. The opportunity to be represented by legal counsel.

7. The opportunity to examine, prior to the review, the evidence upon which the action is based.

8. An impartial decision-maker, whose determination is based solely on whether the Georgia WIC

Program has correctly applied Federal and State statutes, regulations, policies and procedures

governing the Program, based on the evidence presented.

9. Written notification of the decision, including the basis for the decision, within 90 days from the date of

the receipt of a vendor's request for an administrative review.

10. If the disqualification for mandatory or state sanction is upheld by the Administrative Review Process,

the vendor shall be subject to reimbursement for redemption of WIC food instruments from the date of

disqualification through the conclusion of appeals process, eg. Agency Reviews, OSAH, and Judicial

Review.

11. At the time of the request for Administrative Review, the vendor may elect to continue participating in

the Georgia WIC Program. A vendor may decide to waive the election to continue to participate in the

Georgia WIC Program.

12. Neither the vendor nor it's (affiliates) shall be eligible to participate in the Georgia WIC Program until

such time as full reimbursement is made. The vendor may not circumvent reimbursement by selling or

otherwise making any changes or amendments to the corporate structures, since the time of the initial

approval by the Georgia WIC Program.

Form 3746 (Revised 07/2009)
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GA WIC 2010 PROCEDURES MANUAL

Attachment VM-3

Georgia WIC Program Vendor Handbook
Effective October 1, 2010

WIC WORKS WONDERS with PARTNERS
VM-25

GA WIC 2010 PROCEDURES MANUAL

Attachment VM3 (cont'd)

Table of Contents
Glossary ........................................................................................................................................................................
The Vendor Handbook ................................................................................................................................................
The Georgia Women, Infants and Children (WIC) Program..................................................................................
WIC Acronym and Logo..............................................................................................................................................
Authorized Vendors..................................................................................................................................................... Vendor Authorization
Denial of Vendor Authorization............................................................................................................................. Denial of Vendor Authorization or Re-Authorization ........................................................................................
Peer Groups ................................................................................................................................................................... Responsibilities and Procedures for Selected Vendor Types
Corporate Vendors ................................................................................................................................................... Pharmacy Vendors ................................................................................................................................................... Prohibition Against Certain Vendors ....................................................................................................................
Vendor Training Authorization Training Non Corporate Vendors.............................................................................................. Authorization Training Corporate Vendors ...................................................................................................... Annual Training Non Corporate Vendors ......................................................................................................... Annual Training Corporate Vendors.................................................................................................................. Customized Training................................................................................................................................................
WIC Approved Foods ..................................................................................................................................................
List of Infant Formula Suppliers.................................................................................................................................
Minimum Inventory Requirements ..........................................................................................................................
Policy for Granting Waivers........................................................................................................................................
Non WIC Inventory Requirements ............................................................................................................................
The WIC Voucher .........................................................................................................................................................
Voucher Descriptions...................................................................................................................................................
Processing WIC Vouchers WIC Customer Transactions at the Store .............................................................................................................. USDA's Rule on Cost Containment ....................................................................................................................... Return Voucher Payment Procedure ..................................................................................................................... The Vendor Stamp....................................................................................................................................................
Changes in Vendor Information Changes in Store Location .......................................................................................................................................
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Attachment VM3 (cont'd)

Changes in Ownership and Cessation of Operations..........................................................................................
Performance Compliance Covert Compliance Investigations ......................................................................................................................... Audits ......................................................................................................................................................................... Programmatic Reports ............................................................................................................................................. High Risk Identification...........................................................................................................................................

Termination, Termination for Cause, and the Sanction System Termination ............................................................................................................................................................... Sanctions .................................................................................................................................................................... The Sanction System.................................................................................................................................................
Disqualification .............................................................................................................................................................
Administrative Reviews and Appeal Procedures Actions Subject to Administrative Review............................................................................................................ Actions Not Subject to Administrative Review.................................................................................................... Administrative Review Procedures .......................................................................................................................
Inadequate Participant Access Cases .........................................................................................................................
CMP Methodology for Mandatory Sanctions...........................................................................................................

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Attachment VM3 (cont'd)

GLOSSARY
Above 50% Vendors - A vendor that derives more than 50 percent of their annual food sales revenue from WIC food instruments, and new vendor applicants expected to meet this criterion under guidelines approved by FNS.
Automatic Clearing House (ACH) - An electronic funds transfer network which enables participating financial institutions to distribute electronic credit and debit entries to bank accounts and to settle such entries.
Administrative Review - A hearing process offered to vendor in an attempt to challenge decisions made by the program.
Affiliates - Any partner, member, owner, officer, director, employee, relative by blood or marriage, heirs, or assigns.
Annual Training - An annual mandatory participation for all vendors to receive program updates and reminders and verify their receipt and understanding of program updates and reminders.
Cash-Value/Fruit and Vegetable Voucher (CVFVV) - A fixed-dollar amount check, voucher, electronic benefit transfer (EBT) card or other document which is used by a participant to obtain authorized fruits and vegetables.
Civil Money Penalty - A monetary penalty that can be submitted in lieu of a sanction.
Contracted Brand Infant Formula - All infant formulas (except EXEMPT INFANT FORMULAS) produced by the manufacturer awarded the infant formula cost containment contract.
Corporate Vendor - A WIC authorized vendor that has the more than one store with the same FEIN.
Covert Compliance Investigation or Compliance Buy - A covert, onsite investigation in which a representative of the WIC Program poses as a participant, parent, or caretaker of an infant or child participant, or proxy, transacts one or more food instruments, and does not reveal during the visit that he or she is a program representative.
Customized Training - Training that vendors can request to suit their specific training needs.
Days - in WIC terminology means calendar days, unless otherwise noted.
Delivery - The act of transferring a product from a seller to its buyer outside the confines of the retail food establishment.
Disqualification - The act of ending the Program participation of a participant, authorized food vendor, or authorized State or local agency, whether as a punitive sanction or for administrative reasons: Termination of vendors from the Georgia WIC Program for program violations..
Documentation - The presentation of written documents which substantiate statements made by an applicant or participant or a person applying on behalf of an applicant.

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GA WIC 2010 PROCEDURES MANUAL

Attachment VM3 (cont'd)

Exempt Infant Formula - An infant formula that meets the requirements for an exempt infant formula under section 412(h) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 350a(h)) and the regulations at 21 CFR parts 106 and 107.
First date of use - The first date on which the food instrument may be used to obtain supplemental foods.
Food Instrument - A voucher, check, electronic benefits transfer card (EBT), coupon or other document which is used by a participant to obtain supplemental foods.
Food Sales - Sales of all Supplemental Nutrition Assistance Program (SNAP) eligible foods intended for home preparation and consumption, including meat, fish, and poultry; bread and cereal products; dairy products; fruits and vegetables. Food items such as condiments and spices, coffee, tea, cocoa, and carbonated and noncarbonated drinks may be included in food sales when offered for sale along with foods in the categories identified above. Food sales do not include sales of any items that cannot be purchased with SNAP benefits, such as hot foods or food that will be eaten in the store.
Food Sales Establishment License - A license granted by the Georgia Department of Agriculture which permits the retail food vendor to sell food items.
High-Risk Vendor - A vendor identified as having a high probability of committing a vendor violation through application of the criteria established in 246.12(j)(3) and any additional criteria established by the State agency.
Inadequate Participant Access - Not another WIC authorized vendor within 10 miles of another WIC authorized vendor.
Inventory - Supplemental foods in stock, received, and issued.
Inventory audit - The examination of food invoices or other proofs of purchase to determine whether a vendor has purchased sufficient quantities of supplemental foods to provide participants the quantities specified on food instruments redeemed by the vendor during a given period of time.
Last Date of Use - The last date on which the food instrument may be used to obtain authorized supplemental foods.
Mandatory Sanction - Reprimand for violating the program imposed by USDA.
Minimum Inventory - Required inventory that all vendors must carry everyday at all times, including, but not liminted to, fruits and vegetables, and whole grains. Pharmacies are exempt from keeping minimum inventory.
Non-Contract Brand Infant Formula - All infant formula, including exempt infant formula, that is not covered by an infant formula cost containment contract awarded by that State agency.
Non-Corporate Vendor - A WIC Authorized vendor that has only one store or a vendor with more than one store, each with a different FEIN.

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Non-WIC Inventory - Food items that are not a part of the WIC minimum inventory or the WIC Approved Foods List.
Participants - Pregnant women, breastfeeding women, postpartum women, infants and children who are receiving supplemental foods or food instruments under the WIC Program, and the breastfed infants of participant breastfeeding women.
Pharmacy Vendor - A WIC authorized vendor that is allowed to only redeem exempt and/or special infant formulas, including medical foods. No contract formula or other standard WIC food sales are allowed for these vendors.
Pre Approval Visit - An on-site visit to a vendor's retail food establishment to verify location and inventory.
Price Adjustment - An adjustment made by the State agency, in accordance with the vendor agreement, to the purchase price on a food instrument after it has been submitted by a vendor for redemption to ensure that the payment to the vendor for the food instrument complies with the State agency's price limitations.
Proxy - Any person designated by a woman participant, or by a parent or caretaker of an infant or child participant, to obtain and transact food instruments or to obtain supplemental foods on behalf of a participant.
Purchase price - A space for the purchase price to be entered.
Offense or Violation - An act against the programs rules, regulation, policies or procedure.
Overt Monitoring or Routine Monitoring - Overt, onsite monitoring during which program representatives identify themselves to vendor personnel.
Re-authorization training - A mandatory re-certification training that all vendors participate in every three (3) years.
Redemption - The act of cashing the WIC voucher according to WIC banking standards.
Redemption period - The date by which the vendor must submit the food instrument for redemption. This date must be no more than 60 days from the first date on which the food instrument may be used.
Sanction - A penalty that is imposed when WIC program rules, regulations, policies or procedures are violated.
Sign or Signature - A handwritten signature on paper or an electronic signature.
State agency - The health department or comparable agency of each State. In this instance, The State of Georgia WIC Program.
Supplemental Nutrition Assistance Program (SNAP) - (SNAP) is the new name for the federal Food Stamp Program.
Termination - Discontinuance of vendor participation in the Georgia WIC Program.

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Vendor - A sole proprietorship, partnership, cooperative association, corporation, or other business entity operating one or more stores authorized by the State agency to provide authorized supplemental foods to participants under a retail food delivery system. Each store operated by a business entity constitutes a separate vendor and must be authorized separately from other stores operated by the business entity. Each store must have a single, fixed location, except when the authorization of mobile stores is necessary to meet the special needs described in the State agency's State Plan in accordance with 246.4(a)(14)(xiv).
Vendor Authorization - The process by which the State agency assesses, selects, and enters into agreements with stores that apply or subsequently reapply to be authorized as vendors.
Vendor Identification - A number assigned to all authorized vendors. Redemption activity must be identified by the vendor that submitted the food instrument. Each vendor operated by a single business entity must be identified separately.
Vendor Number - A unique four digit number that is used to identify vendors authorized to provide WIC food items.
Vendor Peer Group System - A classification of authorized vendors into groups based on common characteristics or criteria that affect food prices, for the purpose of applying appropriate competitive price criteria to vendors at authorization and limiting payments for food to competitive levels.
Vendor Overcharge - Intentionally or unintentionally charging the State agency more for authorized supplemental foods than is permitted under the vendor agreement. It is not a vendor overcharge when a vendor submits a food instrument for redemption and the State agency makes a price adjustment to the food instrument.
Vendor Selection Criteria - The criteria established by the State agency to select individual vendors for authorization consistent with the requirements in 246.12(g)(3) and (g)(4).
Vendor Training - The procedures the State Agency will use to train vendor in accordance with federal regulation 246.12(i).
Vendor Violation - Any intentional or unintentional action of a vendor's current owners, officers, managers, agents, or employees (with or without the knowledge of management) that violates the vendor agreement or Federal or State statutes, regulations, policies, or procedures governing the Program.
WIC - The Special Supplemental Nutrition Program for Women, Infants and Children authorized by section 17 of the Child Nutrition Act of 1966, 42 U.S.C. 1786
WIC Approved Foods - Those supplemental foods containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants and children.
WIC-eligible medical foods - Certain enterable products that are specifically formulated to provide nutritional support for individuals with a diagnosed medical condition, when the use of conventional foods is precluded, restricted, or inadequate.

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THE VENDOR HANDBOOK

The Georgia WIC Program Vendor Handbook is intended to serve as a reference and is considered an addendum to the Vendor Agreement. Food retailers (hereafter called vendors), pharmacies and military commissaries should adhere to all the information provided in this book to assure compliance with federal and state regulations, policies and procedures.
The vendor's role is important to the success of the Georgia WIC program. Vendors must assure that the participant, parent, caretaker and/or proxy, also known as the WIC customer, purchase only the prescribed foods.
Prices charged by the vendor must be reasonable and competitive. Competitive prices will enable the Georgia WIC program to maximize services to its citizens. Authorized WIC vendors redeemed approximately 253 million in WIC food vouchers during federal fiscal year 2008.

THE GEORGIA WIC PROGRAM

WIC (Women, Infants and Children) special supplemental food program, is a federally funded program that provides supplemental foods, nutrition education and counseling to Georgia's citizens.

WIC saves lives and improves the health of nutritionally at-risk women, infants and children.

Since it's beginning in 1974, the WIC program has earned the reputation of being one of the most successful federally funded programs in the United States. Collective findings of studies, reviews and reports illustrate that the WIC program is cost-effective in protecting and improving the nutritional status of low-income women, infants and children.

Improved outcomes attributed to WIC:
x WIC reduces fetal deaths and infant mortality. x WIC reduces low birth weight rates and increases the duration of pregnancy. x WIC improves the growth of nutritionally at-risk infants and children. x WIC decreases the incidence of iron deficiency anemia in children. x WIC improves the dietary intake of pregnant and postpartum women and improves weight gain in pregnant
women. x Pregnant women participating in WIC receive prenatal care earlier. x Children enrolled in WIC are more likely to have a regular source of medical care and have more up to date
immunizations. x WIC helps children get ready to start school; children who receive WIC benefits demonstrate improved
intellectual development. x WIC significantly improve children's diets.

Georgia's health professionals determine who is eligible to participate in the WIC program. They also provide nutrition education, counseling and prescribe nutritious foods. Instruments used to obtain the supplemental foods are called vouchers, which are redeemed through authorized food retailers statewide.

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WIC ACRONYM AND LOGO
A WIC vendor is not permitted to use either the acronym "WIC" or the WIC logo pictured above, including close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or in the name under which it does business, if different.
Any person who uses the acronym "WIC" or the WIC logo in a non-authorized manner, including close facsimiles thereof, in total or in part, may be subject to injunction by the United States Department of Agriculture and the payment of damages.
The WIC authorized vendor is not permitted to use the WIC acronym, or the WIC logo including close facsimiles thereof in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program, including wording such as, but not limited to, "WIC Only". The state agency will make a determination and notify the vendor if misuse is determined. If a vendor fails to discontinue the use of the WIC acronym or the WIC logo including close facsimiles thereof, in total or in part, after misuse is determined, the Vendor Application will be denied or the Vendor Agreement will be terminated, for cause, as allowed in CFR246.12 (h)(3)(xvi).
The Vendor is permitted to use shelf talkers or channel strips stating "WIC approved or WIC eligible" on grocery shelves at the exact spot that contain WIC approved foods. These items have been developed by the WIC Program and are available upon request. Vendors who wish to develop their own shelf talkers or channel strips must obtain written permission from the Georgia WIC Program by submitting a copy or sample of the final version prior to use.
AUTHORIZED VENDORS
An authorized vendor is a sole proprietorship, partnership, cooperative association, corporation or other business entity operating one or more vendors. A vendor is authorized to provide approved supplemental foods to participants, parents, caretakers and/or proxies. The program is operated in accordance with federal laws and regulations, the Georgia State Plan of Program Operations and Administration and the policies and procedures of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.
VENDOR AUTHORIZATION
Applications for WIC vendor authorization are accepted year round. However, no applications will be mailed, accepted or processed between August 1 September 30 of each year unless inadequate participant access exists (Inadequate participant access exists only when there is not an authorized WIC vendor within 10 miles of the applicant).
All applicants must meet the selection criteria at the time of application and maintain the criteria throughout the entire agreement period. The Georgia WIC Program may deny the application or terminate the vendor agreement if it is determined that the applicant provided false information in conjunction with the application. The selection criteria are the same for vendors statewide with the exception of commissary and pharmacy vendors. The criteria include but are not limited to: 1) Competitive prices 2) Compliance with Georgia WIC Program policies and procedures 3) Licensure by the Georgia Department of Agriculture to sell food items 4) Effective October 1, 2009, licensure by the United States Department of Agriculture as a retail vendor with the
Supplemental Nutrition Assistance Program (formally the Food Stamp Program). 5) Minimum variety and quantity of supplemental foods 6) A substantial inventory of non-WIC approved foods 7) Business integrity 8) Absence of current Supplemental Nutrition Assistance Program disqualification or civil money penalty for
hardship 9) Must not be expected to derive more than 50% of your total food sales from the sale of WIC foods.
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Denial of Vendor Authorization or Re-Authorization based on selection criteria

During the authorization or the Re-Authorization process, vendors may be denied for any of the following reasons:

Application Submitted Outside Timeframe The applicant submitted the initial application between the dates of August 1 and September 30. During this time period, new applications are not accepted or processed. Requested Information not provided The applicant did not provide the necessary documentation as requested. Insufficient WIC Inventory The applicant did not have the minimum variety and/or quantity of WIC approved supplemental foods required during the on-site pre-approval visit. Inadequate Access The store is not open 8 hours per day, six days per week. Prices Exceed Average Redemption Allowed Shelf prices exceeded the Maximum Allowable Reimbursement Level (MARLS) currently allowed for Georgia WIC Program applicants/vendors as assessed during the pre or post price assessment. SNAP Disqualification or Civil Money Penalty Assessment Applicant has been disqualified from the Supplemental Nutrition Assistance Program (SNAP) or has been assessed a Civil Money Penalty for hardship and the disqualification period that would otherwise have been imposed has not expired. History of Georgia WIC Sanctions Applicant has been disqualified and all administrative appeals have been exhausted. Business Integrity Applicant has a conviction or civil judgment. Applicant provided false statements, false representations, or used false writing or documentation. Applicant is expected to derive more than 50% of it's annual food revenue from WIC foods. Ownership has been linked to a current 50% vendor. Owner related by blood, marriage, partners, members, owners, officers, directors, employees, heirs or assigns purchased store to circumvent a sanction or disqualification of another vendor. Use of the Acronym or Logo Applicant used the WIC Acronym or Logo as a part of their name, the name under which they do business or advertisements.

PEER GROUPS
Vendors are placed into peer groups (see below) based on the type and/or square footage of the store including storage areas and the number of stores in the chain.

Peer Group 1 2 3 4 5 6
7 8

Type

Description

SMALL

0 to 5,000 Square Feet

AVERAGE

5,001 to 10,000 Square Feet

MEDIUM

10,001 to 15,000 Square Feet

CHAIN

>15,001 Square Feet and 20 or more locations

MILITARY COMMISSARY Located on Military Bases serving military personnel only

PHARMACY

Pharmacy Redeem exempt and/or special infant formulas only, including medical foods. No contract formula, stated infant formula or other standard WIC foods are allowed for this peer group.

LARGE INDEPENDENT >15,001 Square Feet and less than 20 locations

ABOVE 50% VENDORS

Authorized Vendors who derive more than 50% of their annual food sales revenue from WIC food instruments.

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RESPONSIBILITIES AND PROCEDURES FOR SELECTED VENDOR TYPES
Corporate Vendors
A business entity having two (2) or more stores operating under the same Federal Employer Identification Number (FEIN) and a corporate/home office or single owner/business entity that serves as the parent, shall be classified as a corporate vendor. An authorized representative of the corporate office shall sign one agreement and list pertinent information about each store on Corporate Attachment Form 3771A. Corporate vendors must send a representative(s) to the Authorized Training session and afterwards ensure that all training topics are provided to a management representative(s) in each store. The Corporate Training Checklist Form 3757A must be completed and returned to the Georgia WIC Program, documenting that training has occurred in each store. Signature of the store's management representative is required on this form.

To add a new store, the corporate vendor must first amend their agreement by submitting the corporate Attachment Form 3771A that includes required information about the new location and a corporate Vendor Training Checklist. The new store shall not begin to accept vouchers until a vendor stamp has been received.

Pharmacy Vendors
Pharmacy vendors may redeem exempt and/or special infant formula only, including medical foods. No contract formula, stated infant formula or other standard WIC foods are allowed for this peer group. Pharmacy vendors are exempt from maintaining minimum inventory requirements. Programmatic reports will be used to verify performance compliance, such as whether a pharmacy vendor is redeeming only exempt infant formula vouchers. If authorized pharmacy vendors wish to change their classification to allow for the redemption of all WIC approved foods, a new application must be submitted. Note: Pharmacy vendors shall not accept vouchers through the mail, nor mail any approved formula/medical foods directly to the WIC customer. Termination for cause may occur if this is violated, as allowed in CFR246.12(h)(3)(xvi).

PROHIBITION AGAINST CERTAIN VENDORS - CONSOLIDATED APPROPRIATIONS ACT 2005

A new for profit vendor will not be authorized if that vendor is expected to derive more than 50 percent of its annual food sales revenue from WIC food instruments, unless that vendor is necessary to assure participant access to program benefits. Participant access is assured by the presence of an authorized WIC vendor within 10 miles of the vendor applicant. This includes a new store location for any ownership entity that currently has a WIC authorized store, as well as an entirely new vendor applicant. This provision does not apply to the reauthorization of a current store location operated by a currently authorized vendor. All vendors are required to submit food sales data upon request in order to monitor compliance with the above 50 percent criterion. Effective January 1, 2010, vendors found to be above 50% vendors will be terminated from the WIC Program. Vendors terminated for Above 50% status can request an Abbreviated Administrative Review.

VENDOR TRAINING

Vendor training, including annual training, will be conducted to inform vendors of the appropriate program policies and procedures in one of the following formats: newsletters, videos, videoconferences, or interactive training sessions. Training must be completed with a score of 80 or above on the training evaluation before a preapproval visit will occur.

Authorization Training for Non Corporate Vendors
The Georgia WIC Program will provide an authorized training session in an interactive format prior to, or at the time of authorization. Attendance at training will be documented, a checklist of items discussed will be signed and a Post Vendor Training Evaluation (multiple choice test) will be given. A passing score of eighty (80) is required to become authorized.
Attendance at a training session, prior to becoming an authorized vendor, does not grant the right to begin accepting WIC vouchers. Only a fully executed agreement, signed by both parties and the receipt of a vendor stamp constitutes authorization.

Authorization Training for Corporate Vendors
A representative of the Corporate Vendor must initially complete the authorized training session and receive a passing score of eighty (80) or above. After completing and passing the training session, a corporate vendor is

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allowed to conduct Authorization Training for 1) existing authorized stores at the time of re-application and 2) new

unauthorized stores that will be added to an existing Vendor Agreement. Any corporate vendor must

subsequently conduct authorization training for existing and new locations.

The corporate vendor shall submit documentation (Corporate Vendor Training Checklist) verifying that a management representative of each store has completed authorization training that includes the required training topics that are listed on the Corporate Vendor Training Checklist. Note: The corporate vendor has the option to allow any of their store representatives to attend the authorized training sessions conducted by WIC Program Representatives.

Corporate Vendor Training conducted prior to becoming an authorized vendor does not grant the right to begin accepting WIC vouchers. Only receipt of the vendor stamp (for corporate vendors only) constitutes authorization.

Annual Training for Non Corporate Vendors
The WIC Program will conduct training annually to all vendors regarding changes and updates to policies and procedures. Annual training may be conducted in a variety of formats including newsletters and addendums. Authorized vendors must document participation in annual training by the deadline specified. Failure to do so will result in termination of the Vendor Agreement by giving a 21day advance notice.

Annual Training Corporate Vendors
The WIC Program will conduct training annually to inform corporate vendors of changes and updates to policies and procedures. Annual training may be conducted in a variety of formats including newsletters and addendums. Corporate vendors must first document their participation in annual training by the deadline specified. In addition, the corporate vendor must ensure that each store listed in the current Vendor Agreement receives annual training by the deadline specified. Failure to provide documentation that each store participated in Annual Training will result in termination of the store(s), after a 21day notice.

Customized Training
The Georgia WIC Program Representatives may conduct training for employees of WIC vendors at their request. Training should be requested in writing to the Georgia WIC Program, Vendor Management Unit 2 Peachtree Street, Suite 10-476, Atlanta, Georgia, 30303. Please specify the desired training topic(s) and the type and number of employees who will attend. Both parties will mutually agree upon location and dates.

WIC APPROVED FOODS
The WIC Approved Foods, listed on the WIC Vendor Management website and provided in training, are foods that are available to the WIC customer. ONLY these foods are allowed to be purchased by the participant or proxy presenting the voucher. Brand names and types of infant formula as well as special medical foods are too numerous to list on the chart. Instead, they will be printed directly on the front of the voucher. The WIC customer is allowed to purchase the brand, type and size of infant formula or medical food that is printed on the front of the voucher. Do not allow the WIC customer to purchase infant formula or medical food that is NOT listed on the voucher. The vendor will receive an updated list of approved foods any time changes are made. Vendors will periodically receive pamphlets and posters of WIC approved food items that can be used as marketing displays or as a training resource.

LIST OF INFANT FORMULA WHOLESALERS, DISTRIBUTORS, RETAILERS AND MANUFACTURERS
All currently authorized WIC vendors and all stores applying for WIC authorization are required to purchase infant formula solely from a list of suppliers selected and approved by the Georgia WIC Program. The list is located on the World Wide Web at www.health.state.ga.us/programs/WIC/vendorinfo.asp, click on Approved Infant Formula Suppliers. Acrobat reader must be installed on the computer to view the list. If a supplier is not listed, a vendor is required to call 866-814-5468 or 404-657-2900 to inquire about adding them to the list. After the vendor has requested the addition, the vendor must ensure that the Georgia WIC Program has authorized the supplier, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained according to the terms of the WIC Vendor Agreement.

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MINIMUM INVENTORY REQUIREMENTS
The WIC customer may receive vouchers for specific kinds of highly nutritious foods. Vendors are REQUIRED to maintain in stock, a minimum variety and quantity of the WIC foods below. Pharmacies are exempt.

Food Item MILK
Least Expensive Brand of type selected/allowed
CHEESE
Least Expensive Brand of type selected/allowed
EGGS
Least Expensive Brand
PEANUT BUTTER
BEANS / PEAS / LENTILS
JUICE
WHOLE GRAINBREAD
CEREAL *Whole Grain
FISH
Least Expensive of type selected

Georgia WIC Program Minimum Inventory Requirements
Effective October 1 , 2009 Type/Brand
x Whole Milk x Fat free/Skim, Low-fat (1%), Reduced Fat (2%) Milk x Dry powdered milk (Makes 3 quarts)
x One pound package (2 types)
x 1 Dozen carton, Grade A Large
x Any brand Creamy, Crunchy, or Extra Crunchy (Regular or Low-salt)
x Dried Beans / Peas / Lentils - 3 one pound packages (2 types) x Canned Beans / Peas / Lentils - 14 to 16 oz cans (2 types) x 46-48 oz Ready to Serve Container (2 types) x 64 oz Ready to Serve Container (2 types)
x Whole Grain Bread - (16 oz loaf)
x 11-36 oz (4 types, 2 must be whole grain)
x Tuna - 5 oz Can x Pink Salmon - 7.5 oz or 14.75 oz

Minimum Inventory 12 Gallons 18 Gallons 3 Boxes
8 Pounds
8 Dozen
6 - 18 oz Jars 5 Packages 18 Cans 12 Containers 12 Containers 6 Loaves
24 Boxes 9 Cans 9 Cans

INFANT FORMULA

x Milk Based - Similac Advance EarlyShield - 13 oz Concentrate 62 Cans

x Soy Based - Similac Isomil Advance - 13 oz Concentrate

30 Cans

x Milk Based - Similac Advance EarlyShield - 12.9 oz Powder x Soy Based - Similac Isomil Advance - 12.9 oz Powder

31 Cans 15 Cans

INFANT CEREAL
INFANT FRUIT & VEGETABLES INFANT MEATS
FRUITS &VEGETABLES

x Dry cereal in 8 oz box (2 types, 1 must be rice)
x 4 oz Jars Fruit and /or Vegetable
x 2.5 oz Jars x Fruits - 4 types fresh x Vegetables - 4 types fresh

12 Boxes
96 Jars
93 Meat 10 Pounds Combined 10 Pounds Combined

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NON WIC INVENTORY REQUIREMENT

All vendors are required to carry foods other than WIC approved foods. Pharmacies are exempt. A substantial amount of foods in all of the following categories must be in stock at all times.

Non-WIC Inventory Requirement

Food Item

Type

Meats, Poultry and/or

NON-WIC

Seafood (refrigerated)

Breads and Cereal

NON-WIC

Products

Dairy (i.e. milk, cheese, ice

NON-WIC

cream, yogurt, etc.)

Staples (i.e. flour, sugar,

NON-WIC

pasta, pudding, etc.)

Cans, Jars, Bottled

NON-WIC

Goods (i.e. mayo, ketchup,

relish, etc.)

Beverages (i.e. soda, water,

NON-WIC

powdered drinks, etc.)

Snack Foods (i.e. chips,
cookies, crackers, candy, etc.)

NON-WIC

An onsite inventory audit of the above mentioned food items is a component to the pre-approval and routine monitoring visit.

THE WIC VOUCHER
The WIC voucher is similar to a check. A vendor must accept all valid vouchers, with the exception of a pharmacy vendor, who may redeem exempt and/or special infant formula only, including medical foods (No contract formula, stated infant formula or other standard WIC foods are allowed for this peer group). The vendor should not accept altered vouchers.

When vouchers are properly redeemed, the vendor will receive credit for the amount of purchase by depositing the voucher into the bank.

VOUCHER DESCRIPTIONS
There are five (5) types of WIC vouchers: laser printed, blank manual, standard manual, computer generated, and Cash Value/Fruit and Vegetable Vouchers (CVFVV).

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Laser Printed Vouchers: The laser printed voucher is printed at the clinic site at the time of the participant, parent's, caretaker's and/or proxy's visit.

Rev. 9-2006
Blank Manual Vouchers: All information on the voucher is either handwritten or typed. Redeem only for the amount of food indicated. Only one (1) number should appear in each box. X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alterations on the voucher.
0 00
Rev. 9-2006

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Standard Manual Vouchers: All information on the voucher is written or typed by the staff at the clinic.

CLK
Rev. 9-2006
Computer Generated Vouchers: All information on voucher is computer printed.

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CASH VALUE/FRUIT AND VEGETABLE VOUCHERS

The Georgia WIC Program will be implementing new WIC food packages in October 2009. Women and children will be issued a Cash Value/Fruit and Vegetable Voucher (CVFVV) for fruits and vegetables.

x A Cash Value / Fruit and Vegetable Voucher (CVFVV) will be used to purchase approved fresh, frozen, and canned fruits and vegetables. The Georgia WIC Program is in the process of identifying approved products and will provide you with additional resources at a later date.
x CVFVV's have a maximum amount listed ($6, $8, $10 or $15).

x The WIC participant will be allowed to pay the difference when the cost of their produce exceeds the price stated on the CVFVV. In the past WIC transactions did not include any exchange of money other than the WIC voucher.
x The difference over the CVFVV maximum would be subject to tax, when applicable. The WIC participant would need to pay the difference plus the applicable sales tax.
x You may need to adjust your current procedures to allow for WIC clients to use payment methods such as Food Stamps EBT cards, cash, credit cards, or debit cards to complete the Cash Value / Fruit and Vegetable Voucher transaction.

There is no change in the voucher redemption process for all other vouchers.

PROCESSING WIC VOUCHERS

The vendor's bank should be informed that vouchers are negotiable instruments that must be processed through the Federal Reserve Bank. The Georgia WIC Program will provide each vendor a stamp that is embossed with a unique WIC identification number. All vouchers accepted by the vendor must be stamped with this number in preparation for a bank deposit. Lost, stolen or damaged stamps must be reported to the WIC Branch immediately. DO NOT REPRODUCE THE VENDOR STAMP.

Payment will be assured if: x Voucher(s) are accepted on the "First Day to Use" date through the "Last Day to Use" date. x An authorized WIC vendor stamp appears on the voucher. x Deposited within sixty (60) days of the "First Day to Use" date. x The amount of purchase is entered in the "PAY EXACTLY SPACE", in ink. x A signature is obtained, in ink, at the time of purchase after the amount has been place on the voucher.
WIC Customer Transactions at the Store

WIC participants, parents, caretakers and/or proxies (WIC Customer), redeem WIC vouchers at authorized vendor locations. WIC customers are required to take the WIC ID folder upon each visit to the store. Vendors must request the WIC customer to present the WIC ID folder at the time of the transaction. WIC vendors shall NOT request any other form of identification from WIC customers in order to transact a WIC voucher(s).

WIC foods should be separated from other food purchases prior to the WIC transaction. When approved supplemental food is being purchased with a WIC voucher, the cashier must complete each voucher separately and do the following:
1) For vouchers that contain two signature boxes, check to see if the "Sign here at WIC office" signature box contains a signature.
2) Check the dates on the voucher. Vouchers cannot be used before the "First Day to Use" or after the "Last Day to Use" dates.
3) Ring up the current shelf price of the food for each voucher. Make sure that the exact types and amounts of approved WIC foods are being purchased. Do not include sales tax except during the redemption of the cash value voucher for fruits and vegetables.
4) Print the amount of the WIC purchase in ink, in the "Pay Exactly" space on the voucher in the presence of the WIC customer. Complete this step for one voucher prior to moving on to the next voucher.
5) Credit must not be given to WIC customers in exchange for WIC vouchers.

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6) If the cashier makes a mistake entering the price on the voucher, the incorrect price should be marked

through and the correct price written above the error. The cashier must initial the correction as verification.

7) If the cash registers do not automatically imprint "WIC" on the receipt, cashiers must write "WIC" vertically on

all receipts for food purchased with WIC vouchers.

PROCESSING THE CASH VALUE/FRUIT AND VEGETABLE VOUCHER
Payment will be assured if:
x Cash Value/Fruit and Vegetable Voucher(s) (CVFVV) are accepted on the "First Day to Use" date through the "Last Day to Use" date.
x An authorized WIC vendor stamp appears on the voucher.
x Deposited within sixty (60) days of the "First Day to Use" date.
x The amount of purchase is entered in the "PAY EXACTLY SPACE", in ink.
x .A signature is obtained, in ink, at the time of purchase after the amount has been place on the voucher.
1. For CVFVV's that contain two signature boxes, check to see if the "Sign here at WIC office" signature box contains a signature.
2. Check the dates on the cash voucher. CVFVV's cannot be used before the "First Day to Use" or after the "Last Day to Use" dates.
3. Weigh the fruit or vegetables and/or ring up the current shelf price of the food for each item chosen. Make sure that the exact types of approved WIC foods (fruits and vegetable) are being purchased.
4. If the purchase amount is over the max price listed on the face of the voucher, the participant may pay cash, credit or EBT for the amount over the max price on the cash value voucher.
5. Remember to include sales tax for the difference over the amount on the face of the voucher. 6. Print the amount of the WIC purchase in ink, in the "Pay Exactly" space on the cash value voucher in the
presence of the WIC customer. Complete this step for one cash value voucher prior to moving on to the next cash value voucher. 7. The vendor is permitted to give the participant change for the cash paid for any amount over the max price on the voucher. Change is not permitted for purchase under the amount of the max price listed on the face of the cash value voucher. 8. Credit must not be given to WIC customers in exchange for WIC vouchers. 9. If the cashier makes a mistake entering the price on the cash value voucher, the incorrect price should be marked through and the correct price written above the error. The cashier must initial the correction as verification. 10. If the cash registers do not automatically imprint "WIC" on the receipt, cashiers must write "WIC" vertically on all receipts for food purchased with WIC vouchers.

Cash Value/Fruit and Vegetable Voucher Reminders

The vendor must only provide the supplemental food items listed on the cash value voucher. The voucher must be signed in the presence of the cashier. If any errors are made, mark through the error and write the correct price above it and have the cashier initial the correction. The vendor must not issue change to a WIC customer for purchases less than the total value of a cash value voucher. The WIC Customer can use his/her own funds for purchases in excess of the monetary limit for his/her cash value voucher.

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Important notes about the WIC Customer for Cashiers and Store Managers The WIC customer: 1. Must sign the voucher at the time of purchase. 2. May not use a WIC voucher to purchase items not listed on the voucher. 3. Must never be required to pay cash for items purchased except for items purchased with the cash value voucher. 4. Must be allowed to purchase all foods listed on the food or cash value voucher, regardless of price. 5. Must be afforded the same courtesy given to other store customers. 6. Must be permitted to purchase eligible food items without making other purchases. 7. Must be charged the same shelf prices as other customers. 8. Must not be charged sales tax. 9. Must be reported to the Georgia WIC Program immediately if they attempt to purchase foods that are not approved or create other problems in the store. 10. Must not be required to purchase every item on the voucher. 11. May not be contacted regarding restitution, payment or to obtain a missing signature.
More Important Notes
1. WIC approved foods purchased with a WIC voucher cannot be returned for a cash refund. 2. WIC vouchers must not be accepted from other states. 3. If a manager is called to approve a WIC voucher transaction, it is imperative that the customer is not
identified as a WIC participant, parent, caretaker and/or proxy. Every effort must be made to protect confidentiality and discussion of the transaction should be kept at a conversational level. 4. Separate checkout lines for the WIC customer are prohibited. Signs such as "WIC vouchers not allowed in this line" or "No Checks-No WIC" cannot be displayed since they are considered discriminatory. However, vendors who wish to ensure that the WIC customer does not enter certain lines, such as express lines, may post "Cash Only" signs in those lines. 5. Every store must check the customer's WIC identification card for the proper WIC ID number and authorized signature(s). WIC customers have been instructed about the importance of carrying the WIC ID card to the grocery store when using WIC vouchers. 6. Vendors with self-check out lines must take appropriate steps to verify that the items purchased are WIC approved foods and in the appropriate sizes. 7. Whenever vouchers are lost or stolen from a WIC health facility, the Georgia WIC Program will notify area vendors that a stop payment has been placed on the vouchers. Vendors will be provided the voucher numbers and informed not to accept the vouchers for redemption. These vouchers will not be paid. 8. The vendor must not provide refunds or permit exchanges for authorized supplemental foods obtained with food vouchers or cash value vouchers except for exchanges of the same brand and size of authorized supplemental food item when the original authorized supplemental food item is defective, recalled, spoiled, or has exceeded its "sell by" or "best if used by," or other date limiting the sale or use of the food item. 9. The WIC customer must be allowed to participate in both in-store and/or manufacturer promotions that include WIC approved food items. This includes buy one get one or more free promotions.
10. The WIC authorized vendor, its paid or unpaid owners, officers, managers, agents and employees shall not conduct any conflict of interest activities or similar acts, as determined by the Georgia WIC Program, with the WIC participant, proxy, or caretaker. This includes, but not limited to, instances where an authorized WIC vendor acts as a proxy on behalf of the WIC participant.
11. The vendor is not permitted to provide transportation for the WIC customer to or from the vendor's premises.
12. The vendor is not permitted to deliver WIC approved foods to the WIC customer's residence. 13. The vendor shall not obtain items purchased by the participant nor shall they inquire about obtaining food
items that are not purchased by the participant via the WIC Food Instrument. 14. The vendor must not provide unauthorized food or non-food items, cash, credit (including rain checks) in
exchange for food and cash value vouchers. 15. The Georgia WIC Program will review food vouchers and cash value vouchers submitted for redemption
to ensure compliance with price limitations and to detect suspected vendor overcharges and other errors. 16. Effective January 1, 2010, the Georgia WIC Program may require reimbursement for the full price of the
food voucher or the cash value voucher that contains a vendor overcharge or other error.

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USDA's RULE ON VENDOR COST CONTAINMENT
The dollar amount that a store will be paid for each WIC voucher will be calculated pursuant to the terms and conditions prescribed by and approved by USDA. (See USDA Website at http://www.fns.usda.gov/wic/regspublished/vendorccinterim.pdf) Vouchers that are deposited in your bank, that contain a dollar amount in the "pay exactly box" that exceeds the statewide and/or peer group Maximum Allowable Reimbursement Level (MARLS) will continue to be returned by the bank.
By June 30th of each year, the Georgia WIC Program will assess each vendor to determine if they derive more than 50 percent of their food revenue from WIC food instruments annually and new vendors six months after enrollment.
The State WIC Program implemented a methodology that uses redemption data to determine the maximum allowable reimbursement levels (MARL) for vouchers redeemed monthly.
The State WIC Program implemented new food vouchers and packages for some of the special formulas with corresponding MARL.
The WIC vendor agreement reads as follows:
To accept an adjustment in the amount written in the pay exactly box of the WIC voucher. The amount to be paid will be based upon the average voucher redemption which will be based on the average redemption for all comparable stores in the same peer group and/or the Statewide average for a given time period."
Returned Voucher Payment Procedure
x All authorized vendors are required to enroll in the Automated Clearing House (ACH) for payment of vouchers that exceed the maximum allowable price. At the time of authorization, the ACH Enrollment Form is sent with the Vendor Stamp. The form must be completed and submitted immediately to the address indicated on the form. If the purchase price on a voucher exceeds the maximum allowable price, it will be returned from the bank and stamped "Amount Exceeds Limit Paid via ACH Do Not Resubmit". The voucher will be paid at a rate equal to the average redeemed price for that voucher code for the vendor's peer group.
Payment will be posted to the vendor's bank account immediately. There will be no need to submit the voucher along with the Returned Voucher Payment Log (RVPL) to the State WIC Office nor will there be any delay in payment. Please note that ACH payments will apply only to vouchers that are rejected for exceeding the maximum allowable price. Vendors will be able to view their ACH statements on-line at any time on the WIC Banking website: www.wicbanking.com by entering their personal User ID and Password.
User ID and Passwords will be provided by the WIC Program once the ACH enrollment form has been completed and forwarded to the WIC data processing contractor indicated on the form. Users are urged to change their password when entering the system for the first time. Assistance with changing passwords may be obtained from the State WIC Office, Systems Information Unit at 404-657-2900 or toll free at 1-800-228-9173.
x If a voucher(s) is returned from the bank, submit the returned voucher(s) to the Georgia WIC Program attached to a fully completed RVPL for payment consideration. Vouchers mailed in without the RVPL will be returned unprocessed.
x If it is a vendor's first time submitting vouchers via RVPL, a completed W-9 Form must be included when the vouchers are mailed in. Voucher(s) sent in without a W-9 Form cannot be paid. A W-9 form is an Internal Revenue Service document that collects taxpayer identification number and certification. A copy of the W-9 Form can be found on the last page of this Handbook.
x Vendors must attach a proof of purchase (receipt) for each exempt infant formula and special medical food voucher submitted. Vouchers that are mailed without the required receipt will be returned unprocessed.
x The vendor should retain the last copy of the RVPL for their records. x If a voucher(s) is approved for payment, a copy of the RVPL, along with the payment is forwarded to the
vendor. Price adjustments may be made in the amount that the vendor will be paid. x If a voucher(s) is denied, a copy of the RVPL and the original voucher(s) is returned to the vendor with an
explanation for the denial. x Voucher(s) returned by the vendor's bank stamped "stale date", "post date" "altered" or "signature missing
will not be paid.

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The Vendor Stamp
x Lost, stolen or damaged stamps must be reported to the WIC Program immediately. x Do not reproduce the vendor stamp. x If the inkpad dries out, it is the vendors responsibility to replenish the removable pad. Use black liquid ink
only that is specifically designed for stamping mechanisms. x The vendor stamp is not transferable to another location or individual.
CHANGES IN VENDOR INFORMATION
Changes to the information provided on the vendor application must be communicated to the Georgia WIC Program. This information will be used to update files as necessary. The Georgia WIC Program requires the vendor to provide a 21 day advance written notification of any changes in ownership, store location or cessation of operations.
Changes in Store Location or Information
The vendor must provide the Georgia WIC Program with at least twenty-one (21) days advance notification of any changes in location or information including, but not limited to, name of store. Each store is authorized based on the ownership and street address that exists at the time of authorization and is not transferable to another location. Therefore, if a change in location is ten (10) miles or more from the original store location, the vendor must complete and submit an updated application (non corporate vendor) or corporate attachment form (corporate vendor) and sign a new agreement. If the change in location is less than ten (10) miles from the original store location, the vendor must only complete and submit an updated application or corporate attachment form.
Changes in Ownership and Cessation of Operation
The vendor must submit a notice to the Georgia WIC Program within twenty-one (21) days of any change in ownership or cessation of business (closure) and the effective date. The Georgia WIC Program will acknowledge the receipt of this information. Upon the effective date, the vendor authorization number will be terminated. Any vouchers submitted for payment after the effective date will be returned unpaid. If the vendor wishes to change the effective date, a written notification is required. Otherwise, the vendor authorization number will be terminated, as originally confirmed. Once termination occurs, a vendor must submit a new application and meet all current selection criteria. New owners must submit an application, since WIC vendor agreements are not transferable.

Should the Georgia WIC Program discover that a change in ownership has already occurred, the vendor authorization number will be immediately terminated. All vouchers submitted for payment will be returned unpaid.

Upon the sale of the store, the authorized WIC vendor should inform the new owner that the Georgia WIC Vendor Agreement is non-transferable and that the new owner must submit an application to obtain authorization.

If a Georgia WIC vendor is disqualified from the Georgia WIC Program, the vendor shall not continue operating as a Georgia WIC vendor by selling, assigning or otherwise transferring ownership to the vendor's partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. Failure to abide by this provision may subject vendor to civil liability, fines, and penalties.

Changes in Prices
Each vendor is required to submit the shelf prices for WIC food items carried in each store. The vendor must keep the Georgia WIC Program informed of its shelf prices of the WIC food items sold in its store. The WIC Program collects mandatory shelf prices twice a year in February and November. Effective January 1, 2010, should the vendor change its prices during the interim of those time periods, the vendor must inform the WIC Program of such changes within 48 hours of implementing the prices. The vendor should make the changes on the following website https://sendss.state.ga.us/wicpricing. In the event the vendor fails to update the WIC Program of such change, the WIC Program may rely on the latest submission of shelf prices by the vendor in determining its current shelf prices. Collection of shelf prices is not an approval or denial by the WIC program of the actual shelf prices that the vendor charges WIC participants.

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PERFORMANCE COMPLIANCE
A vendor, with the exception of a military commissary vendor, is subject to compliance performance activities. Any violations that are found may result in sanctions (See Sanction System). Compliance with the Georgia WIC Program policies and procedures is determined using the following methods:
1) Covert (undercover) compliance investigations (military commissary exempt) 2) Overt unannounced monitoring visits (military commissary exempt) 3) Inventory audits (military commissary exempt) 4) Research of programmatic reports and database
Covert Compliance Investigation
During an investigation, if a violation is found, which requires a pattern, the vendor may receive a courtesy notice informing them of the violation. Vouchers received during the covert investigation must be cashed in order to qualify for the courtesy notice of any violation. Vendors who receive notices will be given an opportunity to correct the behavior causing the violation, including training of any personnel involved in WIC transactions. The courtesy notice may include sanctions for violations that occurred which do not require a pattern (see Categories I, II, III under Sanctions). The vendor will be notified if a subsequent violation occurs and will be sanctioned accordingly.
Vendors will not receive prior notice when an investigation has been scheduled. A vendor will not be told of any violation(s) that is discovered while the investigation is ongoing unless a violation requiring a pattern occurs (A violation is considered a pattern if it occurs twice during a covert compliance investigation). In this instance, prior to documenting a second violation, the vendor will receive written notice unless the Georgia WIC Program determines that notifying the vendor would compromise the investigation. A Covert Compliance investigation is considered compromised if:
1. Your vendor status is considered high-risk consistent with Section 246.12(j) (3) of the Special Supplemental Nutrition Program for WIC Program federal regulations.
2. Violation(s) outlined in category VI, and category VII of the Georgia WIC Vendor Sanction System for which no pattern is required.
3. The WIC Program became aware of violations taking place during the course of an on-going investigation, during which time other vendors were found to be in violation of the WIC Program regulations, prompting further investigation.
4. WIC program received complaint(s) against vendor.
5. WIC investigator's identity may be in jeopardy.
6. Threatening conduct or security factors that may occur during the course of a covert/compliance investigation.
7. Covert sting operation by WIC, or in conjunction with other local, state or federal agencies.
8. More than one violation occurred during the initial compliance visit.
Vendors will receive notification of all results including violations after the investigation is considered closed by the WIC Program representatives.
Vendors will be identified for covert compliance investigations via:
1) Research of programmatic reports and vendor database, including but not limited to the Vendor Score section of the Vendor Profile report
2) Vendors who have been reported for potentially violating program policies 3) Random selection
Overt Monitoring
Representatives of the federal or state agencies may conduct unannounced overt monitoring visits any time that the store is open for business. All records pertinent to this monitoring visit must be available for review by the representative of the agency upon request.
Audits
The Georgia WIC Program may conduct record audits on any vendor at any time. Onsite inventory audits will be conducted on vendors that have been investigated with no adverse action and/if the state WIC Program has received a complaint. Inventory audits will include the examination of food invoices or other proofs of purchase to

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determine whether a vendor has purchased sufficient quantities of supplemental foods to provide participants,

parents, caretakers and/or proxies the quantities specified on food vouchers redeemed by the vendor during a

given period of time. During an audit, the vendor must supply the WIC representative with documentation of

pertinent records upon request. Vendors must retain copies of all invoices relating to the purchase of WIC food

items for a period of three (3) years, plus current year.

Programmatic Reports and Database

The WIC Program will research/collect data from specific programmatic reports or databases to identify vendors who may be out of compliance.

If a vendor is out of compliance because of overpricing based on a programmatic report, notification will be given to provide an opportunity to reimburse the Georgia WIC program for the excess amount. Failure to repay will result in a program sanction(s), (see Sanction System).

Programmatic reports will also be generated to determine if a pharmacy vendor is accepting voucher(s) other than those for exempt and/or special infant formulas, including medical foods (No contract formula, stated infant formula or other standard WIC foods are allowed for this peer group). Failure to comply will result in a program sanction.

Programmatic reports, such as the Vendor Profile report will be generated also. If a vendor's score causes a flag in any category, the vendor will be considered high risk and may receive a covert compliance investigation.

HIGH RISK IDENTIFICATION
There are four indicators and scores that will identify a vendor as high risk.
A = 70 or higher (small amount of price variation) B = 70 or higher (large % of food instruments redeemed at same price) H = 7 or higher (vendor has large % of total area redemption) M = 40 or higher (large % of participants outside vendor area)
The four high risk indicators and scores are found in the Vendor Score section of the Vendor Profile report and flagged with an asterisk (*). The report will be mailed annually to keep a vendor apprised of their high risk status.
Vendors found to be High Risk will receive notice indicating why they qualify as high risk including a list of vendor violations that commonly occur during the course of an investigation.
TERMINATION, TERMINATION FOR CAUSE, AND THE SANCTION SYSTEM
Termination
Termination is the ending, by either party, of the agreement between the Georgia WIC Program and the authorized vendor. A written notification of the termination shall be mailed to the affected party at least twentyone (21) calendar days in advance. At the end of the period stated in the 21 day notice, the vendor will be terminated. Reasons for termination, by either party, may include but are not limited to:
1) Voluntary withdrawal from the WIC program. 2) The decision to sell the store. 3) Failure to notify the Georgia WIC Program of a change in ownership. 4) Expiration of the agreement without a new application being submitted. 5) Supplemental Nutrition Assistance Program (SNAP) Disqualification or Civil Money Penalty imposed by
SNAP in lieu of disqualification. 6) Georgia WIC Program disqualification. 7) Failure to participate in and submit documentation of participation in Annual Vendor Training.
At the end of the termination period, you will not be automatically re-instated. You will have to re-apply. You may re-apply anytime after the end of your termination period. You must complete the application process in its entirety. Applications are not accepted between August 1 and September 30 of each year. Any application received during this time will be denied and returned to the vendor for re-submission after October 1.
Termination for Cause
Vendors will be terminated for cause for the following reasons:
1. Use of the WIC acronym or WIC logo, including close facsimiles thereof, in total or in part , either in the
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official name in which the vendor is registered or in the name under which it does business, if different.

2. Pharmacy vendors shall not accept vouchers through the mail, nor mail any approved formula/medical

foods directly to the WIC customer.

3. Failure to complete and submit documentation for annual training by the deadline specified by the

Georgia WIC Program.

4. Failure to inform the Georgia WIC Program of a change in ownership or cessation of operation within at

least 21 days of change and the effective date.

5. Termination for cause for 60 days, including but not limited to the violation of any federal regulation or

terms of the WIC vendor agreement not otherwise covered by the sanction system.

6. Failure to submit or return requested documentation or information by any stated deadline.

Once the vendor has accumulated more than three (3) termination for cause violations, the vendor will be subject to a category 4 sanction. This state agency sanction will not be subject to an administrative hearing but is subject to an Abbreviated Administrative Review of the documentation.

Effective January 1, 2010, in lieu of termination or for vendors in areas of inadequate participant access, vendors can pay a minimum of a $1000.00 Civil Money Penalty and submit the requested documentation and be reinstated immediately. The amount to be paid will be based on the severity of the offense. Subsequent offenses rendering a termination for cause, up to the third termination for cause, will be subject to an increase in Civil Money Penalties. Effective January 1, 2010, the following will be used to determine a Civil Money Penalty for terminations for cause:

Termination for Cause (TFC)- Offense TFC - 1 TFC - 2 TFC - 3

Civil Money Penalty $1000.00 $1500.00 $2000.00

After the third offense rendering a termination for cause and the assessment of a civil money penalty, the vendor will be subjected to disqualification under a Category IV Sanction. After the third offense for vendors in areas of inadequate participant access, the vendor will be subject to the Civil Money Penalty schedule for a Category IV sanction.

Sanctions
Any WIC vendor found to be in violation of federal regulations and/or Georgia WIC Program policy will be assessed a sanction consistent with the severity and nature of the violation. Vendor violations means any intentional or unintentional action of a vendor's current owners, officers, managers, agents or paid or unpaid employees (with or without the knowledge of management) that violates the WIC Vendor Agreement or Federal or State statutes, regulations, policies or procedures governing the Program. Sanctions may include a warning letter, probation, disqualification or a civil money penalty. There are two types of sanctions, State Agency and Mandatory. State Agency sanctions are developed by WIC Program representatives and have obtained approval from United States Department of Agriculture (USDA) prior to implementation. Mandatory sanctions are developed by USDA. Implementation is required and cannot be omitted from the sanction system. Both State Agency and Mandatory Sanctions must be enforced when violation exists.
Violations are categorized by the nature and severity of the violation and shall determine which sanction will be assessed, the duration of the probationary period, and/or the period of disqualification. Each category has a prescribed period of disqualification, probation or warning assessed. Therefore, sanctions shall be assessed as follows:
1) The highest sanction assessed to a vendor shall determine the period of probation or disqualification. 2) All State Agency Sanctions and warnings assessed are retained in the vendor's file for a period of one year
and will roll off in one year. 3) Probationary periods are not subject to an Administrative Review. Vendors will continue to operate their
business during the probationary period. A vendor found to be in violation of WIC policies and procedures during the probationary period will be disqualified for the full probationary period. 4) If a disqualification for a mandatory sanction is not upheld during the administrative review process, then the remaining State Agency Sanction(s), if any, will remain on the vendor's record for one year.
5) Effective January 1, 2010, vendors will be subject to reimbursement of food instruments beginning with date of disqualification and through and until the administrative review and appeals process is complete.
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Violations that commonly occur during the course of an investigation are as follows:

1. Buying or selling vouchers for cash. 2. Overcharging on WIC Vouchers 3. Charging for items not received by the participant. 4. Transacting or redeeming vouchers at an unauthorized location (delivering WIC foods) 5. Failure to write the price on the voucher before the participant signs the voucher. 6. Failure to ring up sales. 7. Prices not marked on items or near shelf 8. Allowing the substitution of one WIC approved food for another WIC approved food. 9. Providing incentive items as a part of the WIC transaction. 10. Providing unauthorized food items in exchange for WIC vouchers.

If a vendor receives a warning letter and decides to dispute it, the vendor may request to be heard by the Georgia WIC Program. To have the decision reviewed, the vendor may select from the following options:
- Call the Georgia WIC Program and speak with the Vendor Management Unit Director. - Submit written correspondence to the Georgia WIC Program. - Request in writing a consultation with the Georgia WIC Program, to be held with the vendor and/or the
vendor's advisor(s).

THE SANCTION SYSTEM
Following is a description of the Georgia WIC Program Sanction System and how it works. Civil Money Penalties (CMP) may be assessed in Categories I-IV in lieu of disqualification for State Agency sanctions only. However, CMP shall only be assessed in lieu of disqualification for mandatory sanctions if the disqualification results in inadequate participant access. Enforcement of all sanctions are required when violations have been committed.

A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item(s) outside of manufacturer's expiration date(s). 2. Charging sales tax on WIC food item(s) other than those purchased witht eh cash value voucher. 3. Failure to allow in-store or manufacturers' promotional or free item(s) with a WIC purchase. 4. Failure to provide WIC participants with a receipt. 5. Failure to check the WIC participants and/or proxy WIC ID card.

Category II - Warning on first offense, second offense-probation for eight (8) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to ring up sales of WIC purchases. 2. Failure to write the price on voucher before the participant signs. 3. Failure to stock the required inventory of contract formula. 4. Failure to stock the required inventory of two or more WIC food items. 5. Refusing to accept valid WIC vouchers from participants. 6. Allowing the substitution of one WIC approved food item listed on the voucher for another WIC approved
food item not listed on the voucher. 7. Allowing the purchase of WIC foods in unauthorized container sizes. 8. Failure to remain open for business at least eight hours per day, six days per week. 9. Failure to repay charges within thirty (30) days.
Category III - Warning on first offense, second offense - probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Contacting WIC participants for any reason regarding a WIC transaction. 2. Requiring participant to pay cash to redeem WIC vouchers, with an exception of cash value vouchers.
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3. Allowing the purchase of any formula other than the one specified on the front of the voucher.

4. Providing incentive items as part of the WIC transaction.

5. One occurrence during a compliance investigation of a violation in Category IV, violations 1-2.

6. One occurrence during a compliance investigation of a violation in Category V, violations 1-5.

7. Requiring WIC Participants to show any identification other than the WIC Identification Card.

B. Any violation from category IV or V that occurs at any time will result in immediate disqualification for the period specified in each category. A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year (twelve months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC vouchers. 2. A pattern of charging for supplemental foods provided in excess of those listed on the voucher.
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives. 7. Prices not marked clearly on WIC food items or near WIC food items. 8. Allowing WIC food items to exceed the quantity specified on the voucher (Except for promotional or free
items). 9. Failure to allow the purchase of any WIC food item(s). 10. Issuing rain checks/IOU's for WIC approved foods. 11. Failure to provide the WIC Program with any changes in vendor information within 21 days of the date
that the change is to take place. (Pertaining to but not limited to name changes, corporate structure, sell or transfer, change of location etc...) 12. Fourth offense rendering a termination for cause following the third assessment of a civil money penalty (This Sanction is subject to an Abbreviated Administrative Review only).

Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of receiving, transacting, and/or redeeming food vouchers in locations different from the
authorized location listed on the Agreement including the use of an unauthorized vendor and/or an unauthorized person, this includes but is not limited to delivering WIC food items to WIC participants and collecting WIC vouchers prior to completing the WIC transaction(s). 2. A pattern of providing credit or non-food items in exchange for WIC vouchers. 3. A pattern of overcharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WIC participant more for food than a non-WIC customer) during a compliance investigation. 4. A pattern of charging for supplemental food not received by the participant, this includes but is not limited to vendor representatives receiving WIC foods omitted by the participants. The WIC participant(s) does not have the authority to give WIC foods to vendor or its representatives and neither the vendor or its representatives shall accept such WIC food items. 5. A pattern of claiming reimbursement for the sale of an amount of a specific supplemental food item which exceeds the store's documented inventory of that supplemental food item for a specific period of time. 6. One incidence of the sale of alcohol or alcoholic beverages or tobacco products in exchange for WIC vouchers.
C. Any violation from category VI or VII that occurs at any time will result in immediate disqualification for the period specified in category VI & VII.
Category VI - Disqualification for six (6) years (seventy-two months) for each violation.
Mandatory Sanctions Violations: 1. One incidence of buying or selling WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.

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Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)].
Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for buying or selling WIC vouchers for firearms. 3. Conviction for buying or selling WIC vouchers for ammunition. 4. Conviction for buying or selling WIC vouchers for explosives. 5. Conviction for buying or selling WIC vouchers for controlled substances.

DISQUALIFICATION
x When a vendor accumulates the maximum number of sanctions, the store shall be disqualified from the WIC program. An exception may be granted when inadequate participant access exists. The disqualification period is determined by the severity and nature of the violation, the number of violations and past disqualifications. Therefore, the highest sanctions assessed to a vendor shall determine the period of probation or disqualification. The actual disqualification period is determined using the same criteria for every vendor. The Georgia WIC Program WILL NOT accept voluntary withdrawal as an alternative to disqualification.
x Disqualification from the WIC Program could also result in a civil money penalty or disqualification from SNAP.
x If a vendor is disqualified or assessed a CMP for a mandatory sanction from the WIC Program in another state, the vendor may be disqualified from the Georgia WIC Program for the same period of time.
x A vendor may be granted a Civil Money Penalty (CMP) in lieu of disqualification when prescribed procedures are met (see Civil Money Penalties and Sanction System). Upon the Georgia WIC Program approval of a CMP, the disqualification period may be waived. Subsequent visits may be conducted during a waived disqualification period. If violations occur during a subsequent visit, the vendor will be disqualified for a period equal to the period that the CMP was assessed or a second CMP may be imposed.
x If a vendor is disqualified from the SNAP Program or assessed a civil money penalty, the vendor shall be disqualified from the WIC Program for the same period of time. (Refer to SNAP Federal Regulations 7 CFR; Part 278.)

ADMINISTRATIVE REVIEW AND APPEAL PROCEDURES
Actions Subject to Administrative Review
If the vendor disagrees with an adverse action(s), an administrative review may be requested. Vendors may request an administrative review for the following reason(s):
1) Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods or the determination that the vendor is attempting to circumvent a sanction.
2) Disqualification. 3) Imposition of a civil money penalty in lieu of disqualification. 4) Denial of authorization based on the vendor selection criteria for business integrity or for a current SNAP
disqualification or civil money penalty for hardship. 5) Denial of authorization because a vendor submitted its application outside the established timeframes. 6) Disqualification based on a trafficking conviction. 7) Disqualification based on the imposition of a SNAP civil money penalty for hardship in lieu of disqualification. 8) Denial of authorization based on the determination that an applicant is expected to meet the >50% Criterion. 9) Denial of authorization based on applicant purchasing infant formula from an unapproved infant formula
supplier, which was not listed on the Approved Infant Formula list. Actions Not Subject to Administrative Review
The following actions are not subject to administrative review pursuant to FNS regulation 7CFRch.11, Part 246.8(iii):
1) The validity or appropriateness of the vendor selection criteria. 2) The validity or appropriateness of the participant access criteria and participant access determinations. 3) The determination whether a vendor had an effective policy or program in effect to prevent trafficking and
that the ownership of the vendor was not aware of, did not approve of, and was not involved in the conduct of the violation. 4) The expiration of a vendor's agreement.
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5) Disputes regarding food instrument payment and vendor claims (other than the opportunity to justify or

correct a vendor overcharge or other error).

6) Disqualification of a vendor as a result of disqualification from the SNAP Program.

7) Determination of vendors above 50% status.

8) Termination for cause for document non-submission, use of the acronym or logo or close facsimiles thereof,

pharmacy vendors use of carrier services to redeem vouchers, failure to complete annual training, failure to

inform the WIC program of change of ownership or location or cessation of operations, or any other

termination for cause including but not limited to the violation of any federal regulation or terms of the WIC

vendor agreement not otherwise covered by the sanction system.

9) A category 4 sanction for Termination for Cause

Vendors requesting an Administrative Review must contact the Georgia WIC Program in writing within twenty-one (21) days of the adverse action. Vendors may choose to be represented by legal counsel. An Administrative Review shall be scheduled only in Atlanta, Georgia at the Office of State Administrative Hearings.

Vendors that are corporations must be represented by an active member in good standing of the State Bar of Georgia who has filed an entry of appearance. This rule does not apply to vendors whose ownership is classified by the Secretary of State's office as sole proprietorship or partnerships.

Administrative Review Procedures
The administrative review process includes the following:
1) Written notification of the adverse action. 2) The opportunity to appeal the action. 3) Adequate advance notice of the time and place of the administrative review. 4) The opportunity to present a case and at least one opportunity to reschedule. 5) The opportunity to cross-examine adverse witnesses (When necessary to protect the identity of WIC
Program investigators, such examinations may be conducted behind a protective screen or other device). 6) The opportunity to be represented by legal counsel. 7) The opportunity to examine, prior to the review, the evidence upon which the action is based. 8) An impartial decision-maker, whose determination is based solely on whether the Georgia WIC Program has
correctly applied Federal and State statutes, regulations, policies and procedures governing the Program, based on the evidence presented. 9) Written notification of the decision, including the basis for the decision, within 90 days from the date of the receipt of a vendor's request for an administrative review. 10) If the disqualification for mandatory or state sanction is upheld by the Administrative Review Process, the vendor shall be subject to reimbursement for redemption of WIC food instruments from the date of disqualification through the conclusion of appeals process, eg. OSAH, Agency Reviews, and Judicial Review. 11) At the time of the request for Administrative Review, the vendor may elect to continue participating in the Georgia WIC Program. A vendor may decide to waive the election to continue to participate in the Georgia WIC Program. 12) Neither the vendor nor it's (affiliates) shall be eligible to participate in the Georgia WIC Program until such time as full reimbursement is made. The vendor may not circumvent reimbursement by selling or otherwise making any changes or amendments to the corporate structures, since the time of the initial approval by the Georgia WIC Program. 13) Vendors will be subject to reimbursement of food instruments beginning with date of disqualification and through and until the administrative review and appeals process is complete.

When the initial decision of a review is ruled in the State's favor,,the vendor may file a motion for reconsideration to the administrative law judge within the time provided by law. When such motions are filed with the Administrative Law Judge, the vendor must also notify the Georgia WIC Program, in writing, within ten (10) days of the initial decision date.
The vendor may choose to request an appeal of the decision within the time provided by law. When such an appeal has been requested, the vendor must notify the Georgia WIC Program in writing that the motion has been filed, within thirty (30) days of the initial decision date. When the initial decision of an Administrative Review is ruled in the State's favor, the vendor may not use the vendor stamp after 10 days of the court filing of its initial decision. A continuation of the usage of the vendor stamp outside of this time period, will result in civil liability.
Prior to the Administrative Review date, if a vendor would like to review their WIC records, contact the Georgia WIC Program in writing for an appointment. The request must be made within the allowable time frames as
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detailed in the code of Federal Regulations 7 CFR 246.18. The Georgia WIC Program will determine the location

for the record review. The vendor may have a legal representative present. In the event an appointment cannot

be negotiated, a conference call may be scheduled. The Georgia WIC Program will mail all the records pertaining

to the adverse action prior to the conference call. The conference call will be documented.

ABREVIATED ADMINISTRATIVE REVIEW
When a vendor has violated the program resulting in a Termination for Cause, a Category IV Sanction for a Termination for Cause, or it has been determined that a vendor is in above 50% status, the vendor may request an Abbreviated Administrative Review within 5 days of the decision to terminate for cause. Continued violation of the program resulting in a termination for cause will be subject to a Category IV Sanction. A Category IV Sanction for a termination for cause is not subject to an Administrative Review, but is allowed the one time opportunity of an Abbreviated Administrative Review. This review will consist of the following:

1. Verification that any requested documentation was received prior to the deadline. 2. Verification that the correct information was identified on the requested documentation. 3. Verification that the process or assessment to determine the vendor's status was proper. 4. Verification that the vendor has exhausted additional opportunities for a Termination for Cause or
exhausted additional opportunities for the assessment of a Termination for Cause Civil Money Penalty. 5. Verification that the decision to terminate is justified.

An Abbreviated Review may be requested in any of the following ways: x Call the Georgia WIC Program and speak with the Vendor Management Unit Director. x Submit written correspondence to the Georgia WIC Program, Vendor Management Unit.

A vendor, who is in an area of inadequate participant access, and who has exhausted the opportunity to be Terminated for Cause, and who has exhausted the opportunity to be assessed additional Civil Money Penalties, will be subject to Civil Money Penalties as assigned to a Category IV Sanction. Termination for Cause is not subject to an appeal or an Administrative Review Process.

INADEQUATE PARTICIPANT ACCESS
Inadequate participant access is granted only when there is not an authorized WIC vendor within 10 miles of the violating vendor. Geographical barriers will be considered. The validity or appropriateness of the participant access criteria and participant access determinations are not subject to administrative review.

If the State Agency determines that disqualifying a vendor causes inadequate participant access, the State Agency must impose a Civil Money Penalty (CMP) in lieu of disqualification in Categories I-VII. The State Agency may not impose a CMP in lieu of disqualification either as a result of a SNAP Program/Civil Money Penalty or for a third or subsequent sanction as specified in 7 CFR 246.12(l)(1)(vi).

Effective January 1, 2010, in lieu of Termination for Cause for vendors in areas of inadequate participant access, vendors can pay a minimum of a $1000.00 Civil Money Penalty and submit the requested documentation and be reinstated immediately. The amount to be paid will be based on the severity of the offense. Subsequent offenses rendering a termination for cause, up to the third termination for cause, will be subject to an increase in Civil Money Penalties. After the third offense for vendors in areas of inadequate participant access, the vendor will be subject to the Civil Money Penalty schedule for a Category IV sanction. For more information pertaining to Inadequate Participant Access for a Termination for Cause violation please refer to the section of this handbook which covers Termination for Cause.

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CIVIL MONEY PENALTIES (CMP)
CMPs may be assessed in lieu of disqualification for State Agency sanctions based on the methodology outlined in the chart below.

Civil Money Penalty Formula for State Agency Sanctions Based on a Six Month WIC Redemption Total

Category

$0-11,000 (Base Rate)

Amount Above $11,000 (Base Rate + % of Total Redemption over $11,000)

Category I

$500

$500 + 1% of redemption over $11,000

Category II $1000

$1000 + 2% of redemption over $11,000

Category III $1500

$1500 + 3% of redemption over $11,000

If a CMP is not requested in the specified time period, all rights to a CMP are forfeited. For State Agency Sanctions, the first CMP will be reduced by 50% if the vendor presents documented proof that they had an effective training program in place. The vendor must also submit documentation listing the names of the personnel trained and the date of training. This training date must be during the fiscal year and before the disqualification notification.
Civil Money Penalties cannot exceed $11,000 per violation and/or $44,000 per investigation. If more than one violation is detected during a compliance investigation, a CMP must be imposed for each violation (up to the $11,000/$44,000 limits). Only two CMPs can be granted within a waived disqualification period.
CMPs must be paid within 30 days of the notice of approval. Installments may be considered up to a maximum of six months. When a CMP is approved, the waived disqualification period will begin as outlined in the disqualification notice. If a vendor fails to pay the CMP, the State Agency must disqualify the vendor for a period equal to the violation for which the CMP was assessed.
CMP Methodology for Mandatory Sanctions
CMPs may only be assessed for mandatory sanctions if the disqualification would result in inadequate participant access. The CMP formula for mandatory sanctions shall be based on 7 CFR 246.12 (l)(1)(x). For a violation that warrants permanent disqualification, the amount of the CMP shall be $11,000.
For each violation subject to a mandatory sanction, the following formula will be used to calculate the amount of the CMP imposed in lieu of disqualification.
1) Determine the vendor's average monthly redemptions for at least the 6 month period ending with the month immediately preceding the month during which the notice of the adverse action is dated.
2) Multiply the average monthly redemptions figure by ten percent (.10). 3) Multiply the product from the figure in the above statement by the number of months for which the store
would have been disqualified. This is the amount of the Civil Money Penalty, provided that the civil money penalty shall not exceed $11,000 per violation. The total amount of the CMP assessed for violations that occur during a single investigation may not exceed $44,000.
When a vendor, who previously has been assessed any mandatory sanction, receives another identical mandatory sanction, the second CMP amount must be doubled. CMPs may only be doubled up to the maximum limits. When a vendor has previously been assessed two or more identical mandatory sanctions, receives a subsequent, yet different mandatory sanction, the CMP amount of this third identical sanction and all subsequent sanctions must be doubled. Civil Money Penalties may not be imposed in lieu of disqualification for third or subsequent mandatory sanctions.

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WHERE TO GET MORE INFORMATION
The Georgia WIC Program has a vendor customer service hotline (toll free in Georgia) available to assist Georgia WIC vendors with any aspect of the WIC Program. The hotline is available Monday through Friday, except State holidays, from 8:00 AM 4:30 PM Eastern Standard Time (EST). After 4:30 PM and during periods of high volume calling, please leave a voice message.
Contact us at: Georgia WIC Program Vendor Management Unit 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303-3142 404-657-2900 Customer service hotline 1-866-814-5468 (toll free within Georgia)

"In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-6382 or (800) 795-3272 (TTY). USDA is an equal opportunity provider and employer."

Form No. 3783 (Rev. 7/2009)

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GEORGIA WIC PROGRAM WIC VENDOR AGREEMENT

Full Legal Name of Store or Corporation
Doing Business As (If applicable)
Street Address
Store location or corporate home office

City Business Telephone

(Area Code)

State
Number

Mailing Address
If different from above. All communications, i.e. disqualifications, sanctions, addendums, annual training, etc. will be mailed to the location listed here.

City

State

Email Address

Fax Number

Federal Employer Identification Number

Registered Agent

Mailing Address
Disqualifications and terminations will be mailed to this address

City

State

DO NOT WRITE BELOW THIS LINE GEORGIA WIC PROGRAM USE ONLY
WIC VENDOR NUMBER (Non-corporate vendors only)

Attachment VM-4
Zip County
Zip
Zip

This Agreement is by and between the Georgia Women, Infant and Children Program, hereinafter known as the "Georgia WIC Program," having a mailing address of Two Peachtree Street NW, Suite 10-476, Atlanta, Georgia, 30303-3142, and the above named vendor hereinafter known as "the Vendor." This agreement is effective for the period beginning ______________________________ and ending September 30, 2010.

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I.

PURPOSE

The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed nutritious supplemental foods in accordance with federal laws and regulations and the Georgia Nutrition Program for Women, Infants and Children (WIC) pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.

II. VENDOR ELIGIBILITY AND LOCATION

A. An eligible vendor is a business entity that is 1) licensed by the Georgia Department of Agriculture and, 2) without a debarment or suspension from United States Department of Agriculture. Military commissaries do not have to be licensed by the Georgia Department of Agriculture.

B. Effective January 1, 2010, an eligible vendor is a business entity that is 1) registered and licensed by the United States Department of Agriculture Food Nutrition Service as a retail participant in the Supplemental Nutrition Assistance Program or SNAP (formally the Food Stamp Program) and 2) is in good standing without debarment or suspension from the United States Department of Agriculture or the SNAP program. Military commissaries do not have to be SNAP participants.
C. An eligible vendor must be identified as a fixed location with an official physical address.
D. For corporate vendors owning two (2) or more locations, the requested information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement.

E. An eligible vendor must meet all requirements as described in the Georgia WIC Program Vendor Handbook and all addendums.
F. The vendor must comply with the selection criteria throughout the agreement period including any changes to the criteria. Using the current vendor selection criteria, the Georgia WIC Program may reassess the vendor at any time during the agreement period. The Georgia WIC Program will terminate the Vendor Agreement if the vendor fails to meet the current vendor selection criteria at reassessment.
G. An eligible vendor, authorized as a military commissary, pharmacy or corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in the Georgia WIC Program Vendor Handbook and all addendums.

III. RESPONSIBILITIES VENDOR

The Vendor agrees to adhere to all federal and state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration and any subsequent revisions to the policies, procedures, laws, rules and regulations issued by the federal government and/or the Georgia WIC Program. This Agreement will be interpreted based on the laws of the State of Georgia.

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A. The vendor agrees and covenants: 1. To be fully accountable for the actions of its paid or unpaid owners, officers, managers, agents and employees. 2. To abide by the rules, policies and procedures as outlined in the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums. 3. To not solicit the WIC customer on the premises of WIC clinics. 4. To solely purchase infant formula, that will be redeemed for WIC vouchers, from the Approved Infant Formula Supplier list. If a supplier is not listed, a vendor is required to call 866-814-5468 or 404-6572900 to inquire about adding them to the list. The vendor must ensure that the requested supplier has been authorized by the Georgia WIC Program, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained according to Section III.I.3 of this Agreement. 5. To submit total food sales and gross sales revenue records, as requested, by Georgia WIC Program. 6. To immediately notify the Georgia WIC Program when greater than 50% of total food sales revenue is derived from the redemption of WIC vouchers. 7. To not use the WIC logo or acronym, including close facsimiles thereof, in total or in part, either in the name in which the vendor is registered or under the name in which it does business, or in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program including such wording as, but not limited to, "WIC Only". 8. To carry a substantial amount of non-WIC food inventory at all times.
B. VENDOR TRAINING
Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The Georgia WIC Program will provide the date, time and location of the training. The vendor may submit a written request, for the Georgia WIC Program to provide subsequent customized training to store personnel at anytime after both parties have signed the agreement.
The vendor agrees and covenants:
1. To provide training to paid and unpaid employees, agents and all personnel involved in WIC transactions.
2. To not participate in the Georgia WIC Program until Authorized Training has been completed and a vendor stamp has been issued.
3. To not participate until the vendor has received a passing score of eighty (80) points or above on the Post Vendor Training Evaluation.
4. To provide documentation that a management representative(s) from each location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (Form 3757A), (Corporate vendors only).
C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES
The vendor agrees and covenants:

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1. To only charge for authorized supplemental foods selected by the WIC customer as listed on the food voucher or cash value/fruit and vegetable voucher and not charge for WIC approved items that are not received.
2. To not provide unauthorized food items, non-food items or cash in exchange for food vouchers or cash value/fruit and vegetable vouchers.
3. To not provide refunds or permit exchanges for authorized supplemental food vouchers except for exchanges of the same brand and size authorized supplemental food item when the original authorized supplemental food item is defective, spoiled, recalled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.
D. FOOD VOUCHER TRANSACTIONS
The vendor agrees and covenants:
1. To not accept WIC food vouchers or cash value/fruit and vegetable
vouchers before the "First Date to Use" or after the "Last Date to Use" as printed on the voucher.
2. To submit vouchers to the bank for payment within sixty (60) days
from the "First Date to Use" as indicated on each voucher.
3. To assure that WIC food voucher transactions are processed in
accordance with the procedures set forth in the recent Georgia WIC Program Vendor Handbook and all addendums.
4. To not demand that a WIC Participant, caretaker and or proxy,
hereafter called the WIC customer, purchase every eligible WIC food item listed on the voucher.
5. To allow WIC customers the right to purchase the eligible foods of
their choice as listed on the WIC food voucher, cash value voucher and the approved food list.
6. To only allow the purchase of supplemental foods listed on the food
voucher and cash value/fruit and vegetable voucher.
7. To ensure that the Georgia WIC Program is not being charged for
foods not received by the participant.
8. To not transfer Georgia WIC Program vouchers from vendor to
vendor.
9. To not accept Georgia WIC Program vouchers from another vendor
for payment.
10. To not accept WIC vouchers or cash value/fruit and vegetable
vouchers in an unauthorized location for payment in an authorized location.
11. To not contact or seek restitution from the WIC customer for WIC food
vouchers not paid or partially paid by the Georgia WIC Program.
12. To not request cash from the WIC customer for any WIC transaction
except for transactions involving the cash value/fruit and vegetable vouchers.
13. To not provide the WIC customer with rain checks/IOU's, credit slips,
due bills or other similar receipts for WIC foods not obtained at the time of the purchase.

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14. To allow WIC customer to participate in in-store and/or manufacturer
promotions that include WIC approved food items. This includes buy one, get one or more free.
15. To not collect sales tax on prescribed WIC food purchases. 16. To not charge the WIC customer or the WIC Program for bank fees or
other fees related to voucher redemption.
17. To advise the WIC customer that the Georgia WIC Program is not
responsible for the home delivery of food items or any other in-store promotions.
18. To insert, in ink the actual cost (shelf price) of the WIC foods in the
"Pay exactly box" at the time of purchase in the presence of the customer, prior to obtaining a signature.
19. To not provide unauthorized food, or non-credit food items, cash,
credit (including rain checks) in exchange for food vouchers and cash value/fruit and vegetable vouchers.
20. To include sales tax for the difference over the amount on the face of
the cash value/fruit and vegetable voucher.
21. To allow the WIC customer to use his/her own funds in excess of the
monetary limits for his/her cash value/fruit and vegetable voucher.
22. To not issue cash change to a WIC customer for purchases less than
the total value of the cash value/fruit and vegetable voucher.
23. To only use the cash value/fruit and vegetable voucher for fruit and
vegetable purchases.
E. PRICING
The vendor agrees and covenants:
1. To clearly mark the price of WIC foods on the item, container, shelf or sign.
2. To provide each WIC food item at or below the current shelf price. 3. To accept an adjustment in the amount written in the pay exactly box
of the WIC voucher. The amount to be paid will be based upon the average voucher redemption which will be based upon the average voucher(s) redemption for all comparable stores in the same peer group and/or the statewide average for a given time period.
F. OVERCHARGING
The vendor agrees and covenants:
1. To not overcharge the WIC customer or the Georgia WIC Program by charging more than the vendor's current shelf price for a WIC approved food item(s), or charging a WIC participant more for food than a non WIC customer. (Overcharging is considered a violation and will result in sanction(s) if it occurs during a covert investigation.
G. VENDOR COST CONTAINMENT
Vendor Cost Containment is intended to assist state agencies in achieving compliance with section 17(h)(11) of the Child Nutrition Act of 1966 (CNA), as amended by the Child Nutrition and WIC Reauthorization Act of 2004 (Public Law 108-265).

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The New requirements underscore the State agency's responsibility to ensure that the program pays all vendors competitive prices for supplemental foods. The State WIC Program implemented a cost containment plan to identify and manage vendors who derive more than 50 percent of their annual food revenue from WIC food instruments.
By June 30th of each year the State WIC Program will assess each vendor as to if they derive more than 50 percent of their food revenue from WIC food instruments annually and new vendors six months after enrollment.
The State WIC Program utilizes a methodology that uses redemption data to determine the maximum allowable reimbursement levels (MARL) for food instruments.
H. CIVIL RIGHTS
The vendor agrees and covenants: 1. To abide by the United States Civil Rights Act and the United States
Civil Rights Policy Statement and to assure that discrimination is prohibited towards WIC customers and all related activities, on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital status. 2. To offer the WIC customer the same courtesies offered to all other customers. 3. To display the "We Welcome WIC'' poster provided by the Georgia WIC Program on the door glass or other prominent place. 4. To assure that all information, including the identity of the WIC customer is kept confidential in accordance with state and federal law.
I. CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION
The vendor agrees and covenants: 1. To submit, upon request, to the Georgia WIC Program a copy of all
acceptable proof of ownership, identity and related documents, (e.g. articles of incorporation, bill of sale and partnership declaration and evidence of sole proprietorship, social security card, driver's license, etc.) 2. To notify the Georgia WIC Program in writing at least twenty-one (21) days in advance if the vendor plans to cease business operation, change ownership, store name or move from the authorized location.
J. PERFORMANCE COMPLIANCE AND CONFLICT OF INTEREST
The vendor agrees and covenants: 1. To permit unannounced visits by federal or state agency
representatives to review adherence to federal laws and to the Georgia WIC Program's policies and procedures. 2. To provide access to WIC food vouchers and/or cash value/fruit and vegetable vouchers on hand, inventory records (invoices) and any

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other business records during a monitoring visit or inventory audit by an authorized federal or state agency representative. 3. To maintain required records for four years or until pending investigations are adjudicated. 4. To disclose any potential or actual conflict of interest between the vendor and Georgia WIC Program employees. 5. To not permit its' paid or unpaid owners, officers, managers, agents and employees to conduct with the WIC customer, any conflict of interest activities or similar acts, as determined by the Georgia WIC Program. This includes, but is not limited to instances where an authorized WIC vendor acts as a proxy for the WIC customer. 6. To not attempt to circumvent a sanction(s) by selling assigning or otherwise transferring ownership to the vendor's partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. 7. To not use the WIC logo or acronym, including close facsimiles thereof, in total or in part, either in the name in which the vendor is registered or under the name in which it does business, or in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program including such wording as, but not limited to, "WIC Only".

K. VENDOR SANCTION SYSTEM AND VENDOR CLAIMS
The vendor agrees and covenants: 1. To pay claims and penalties levied for audit citations and for
sanctions levied pursuant to this agreement and the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums. 2. That the Georgia WIC Program can impose claims, sanctions and penalties as outlined in this agreement and the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums.
L. STATE PROPERTY
The vendor agrees and covenants: 1. To return the vendor stamp(s) to the Georgia WIC Program upon
termination, change of ownership or disqualification. 2. To report lost, stolen or damaged vendor stamps to the Georgia WIC
Program immediately.
IV. RESPONSIBILITIES GEORGIA WIC PROGRAM
The Georgia WIC Program agrees to adhere to federal and/or state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration.

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Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to the Georgia WIC Program issued by the federal government are hereby made a part of this agreement.

The Georgia WIC Program further agrees to the following:

A. To supply the vendor with the most recent publication of the Georgia WIC

Program Vendor Handbook and all addendums.

B. To assure that the WIC customer are informed of the proper voucher

redemption procedures and the correct use of WIC vouchers.

C. To assure that vouchers are provided to qualified women, infants and

children.

D. To notify the vendor of new requirements as set forth by the U.S.

Department of Agriculture's regulations and/or the Georgia WIC

Program's policies and procedures.

E. To provide training for the vendor on policies and procedures of the WIC

Program, at a time, place and in a manner prescribed by the Georgia WIC

Program.

F. To monitor and audit the vendors for possible violations of the Georgia

WIC Program rules, regulations, policies or procedures.

G. To enforce rules, regulations, policies and procedures of the Georgia WIC

Program through a system of claims, penalties, and/or sanctions against

the vendor as described in the most recent publication of the Georgia

WIC Program Vendor Handbook and all addendums.

H. To provide an appropriate written notice of intent or reason(s) to terminate

this agreement.

I.

To notify the vendor of the right to appeal adverse actions.

J. To provide payment for vouchers validly redeemed and submitted to the

Georgia WIC Program as prescribed in the most recent publication of the

Georgia WIC Vendor Handbook and all addendums.

K. To deny payment for vouchers improperly completed, redeemed or

submitted in accordance with the most recent publication of the Georgia

WIC Program Vendor Handbook and all addendums.

L. To refuse authorization to a vendor applicant if it is determined that the

store(s) is being sold in an attempt to circumvent a Georgia WIC Program

sanction.

M. To notify vendor of stolen vouchers. The stolen vouchers may not be

redeemed.

N. To maintain an up to date listing of Approved Infant Formula retailers,

wholesalers, manufactures and distributors, which authorized vendors

must use to purchase infant formula and to approve additional suppliers

upon request.

V. RENEWABILITY

This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the current agreement period, the vendor must reapply for authorization.

VI. NON TRANSFERABILITY

This agreement is not transferable.

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VII. EXPIRATION, TERMINATION AND DISQUALIFICATION

A. Expiration of this agreement is not subject to appeal by the vendor. B. Either party may terminate the agreement. C. The Georgia WIC Program may terminate for cause, after providing the
vendor a twenty-one (21) day advance written notice. Vendors have the right to request an Administrative Review. D. Disqualification is an adverse action taken by the Georgia WIC Program and is based on the sanction system outlined in the Georgia WIC Program Vendor Handbook and all addendums.

VIII. ADVERSE ACTIONS AND REVIEW PROCEDURES

1. A vendor may request an Administrative Review for the following:

A. Denial of authorization based on the vendor selection criteria for

competitive price or for minimum variety and quantity of authorized

supplemental foods or the determination that the vendor is attempting to

circumvent a sanction.

B. Disqualification.

C. Imposition of a civil money penalty in lieu of disqualification.

D. Denial of authorization based on the vendor selection criteria for business

integrity or for a current SNAP disqualification or civil money penalty for

hardship.

E. Denial of authorization because a vendor submitted its application outside

the established timeframes, August 1 September 30 of each year.

F. Disqualification based on a trafficking conviction.

G. Disqualification based on the imposition of a SNAP Civil Money Penalty

for hardship in lieu of disqualification.

H. Termination for cause including, but not limited to, the violation of any

federal regulation covered in the sanction system.

I.

Denial of authorization based on the determination that an applicant

purchased infant formula, which will be redeemed with WIC vouchers,

from an unapproved infant formula supplier which was not listed on the

Approved Infant Formula List.

J. Denial of authorization based on the determination that an applicant is

expected to derive more than 50% of its' annual food revenue from the

sale of WIC vouchers.

Administrative Review Procedures are outlined in the most recent Georgia WIC Vendor Handbook.

2. A vendor may request an Abbreviated Administrative Review for the following Termination for Cause reasons:

A. Use of the WIC acronym or WIC logo, including close facsimiles thereof, in total or in part , either in the official name in which the vendor is registered or in the name under which it does business, if different.
B. Pharmacy vendors shall not accept vouchers through the mail, nor mail any approved formula/medical foods directly to the WIC customer.
C. Failure to complete and submit documentation for annual training by the deadline specified by the Georgia WIC Program.

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D. Failure to inform the Georgia WIC Program of a change in ownership or cessation of operation within at least 21 days of change and the effective date.
E. Termination for cause for 60 days, including but not limited to the violation of any federal regulation or terms of the WIC vendor agreement not otherwise covered by the sanction system.
F. Failure to submit or return requested documentation or information by any stated deadline.
Vendors terminated for Above 50% status can request an Abbreviated Administrative Review.
Abbreviated Administrative Review Procedures are outlined in the most recent Georgia WIC Vendor handbook.
IX. Termination for Cause
A. The Georgia WIC Program may penalize the vendor by terminating the vendor for cause in accordance with the procedure prescribed in the most recent publication of the Georgia WIC Vendor Handbook and addendums.
B. A written notification of the termination shall be mailed to the affected party at least twenty-one (21) calendar days in advance. At the end of the period stated in the 21 day notice, the vendor will be terminated.
C. At the end of the termination period, the vendor will not be automatically re-instated. The Vendor will have to re-apply.
D. Effective January 1, 2010, in lieu of termination for cause, or for vendors in areas of inadequate participant access, the Georgia WIC Program will allow vendors to pay a minimum of a $1000.00 Civil Money Penalty and be reinstated immediately. In instances of termination for cause for nonsubmission of requested documentation, the vendor must pay the penalty and submit the requested documentation. The amount to be paid will be based on the severity of the offense. Subsequent offenses rendering a termination for cause, up to the third termination for cause, will be subject to an increase in Civil Money Penalties.
E. Effective January 1, 2010, after the third offense rendering a termination for cause, the vendor will be subjected to disqualification under a Category IV Sanction.
F. Effective January 1, 2010, after the third offense for vendors in areas of inadequate participant access, the vendor will be subject to the Civil Money Penalty schedule for a Category IV sanction.

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X. PENALTIES
A. The Georgia WIC Program may penalize the vendor by issuing sanctions in accordance with the procedures prescribed in the most recent publication of the Georgia WIC Vendor Handbook and all addendums.
The Georgia WIC Program sanctions may include disqualification, warnings, probation and civil money penalties in lieu of disqualification. The State agency will provide the vendor with prior warning about violations before imposing such sanctions (7CFR 246.12 XVIII), except when notification would compromise the investigation.
B. A vendor maybe subject to criminal penalties as a result of a violation of the Georgia WIC Program in addition to civil money penalties described above. Vendors who have willfully misapplied, stolen or fraudulently obtained WIC funds shall be subject to a fine of not more than $25,000.00 imprisonment for not more than five (5) years or both. If the value of the funds is less than $100.00 then the penalties may be a fine of not more than $1,000.00, imprisonment for not more than one (1) year or both.
C. If a disqualification for a mandatory sanction is not upheld during the administrative review process, then the remaining State Agency Sanction(s), if any, will remain on the vendor's record for one year.
D. Vendors will be subject to reimbursement of food instruments beginning with date of disqualification and through and until the administrative review and appeals process is complete.

XI. SEVERABILITY
If any one provision of this agreement or form attached to or incorporated by reference is waived or held to be invalid, such waiver or invalidity shall not affect other provisions of this agreement.

XII. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS
A. Sanctions - any sanction(s) that are in the vendor's record at the time of re-authorization will remain on the vendor's record for the period of time specified when the sanction was issued. Prior year's sanctions may result in a denial of the authorization of the application and/or additional sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.
B. Violations - Pending and/or potential violations, that exists at the time of re-authorization will accrue and will result in sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.

XIII. SANCTION SYSTEM
Following is a description of the Georgia WIC Program Sanction System and how it is implemented. Civil Money Penalties (CMP) may be assessed in Categories I-IV in lieu of disqualification for State Agency sanctions only. CMP's shall only be assessed for mandatory sanctions listed in Category IV and

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Category V if the disqualification results in inadequate participant access. Vendor violations will be categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall determine the period of probation and disqualification. Disqualification from the WIC program may also result in disqualification from the SNAP Program.
A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item(s) outside of manufacturer's expiration date(s). 2. Charging sales tax on WIC food item(s) other than those purchased with a cash
value/fruit and vegetable voucher. 3. Failure to allow in-store or manufacturers' promotional or free item(s) with a WIC
purchase.
4. Failure to provide WIC participants with a receipt. 5. Failure to check the WIC participants and/or proxy WIC ID card.
Category II - Warning on first offense, second offense-probation for eight (8) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to ring up sales of WIC purchases. 2. Failure to write the price on voucher before the participant signs. 3. Failure to stock the required inventory of contract formula. 4. Failure to stock the required inventory of two or more WIC food items. 5. Refusing to accept valid WIC vouchers from participants. 6. Allowing the substitution of one WIC approved food item listed on the voucher for
another WIC approved food item not listed on the voucher. 7. Allowing the purchase of WIC foods in unauthorized container sizes. 8. Failure to remain open for business at least eight hours per day, six days per
week. 9. Failure to repay charges within thirty (30) days.
Category III - Warning on first offense, second offense - probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Contacting WIC participants for any reason regarding a WIC transaction. 2. Requiring participant to pay cash to redeem WIC vouchers, with an exception of
cash value/fruit and vegetable vouchers. 3. Allowing the purchase of any formula other than the one specified on the front of
the voucher. 4. Providing incentive items as part of the WIC transaction. 5. One occurrence during a compliance investigation of a violation in Category IV,
violations 1-2.

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6. One occurrence during a compliance investigation of a violation in Category V, violations 1-5.
7. Requiring WIC Participants to show any identification other than the WIC Identification Card.

B. Any violation from category IV or V that occurs at any time will result in immediate disqualification for the period specified in each category. A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year (twelve months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC vouchers. 2. A pattern of charging for supplemental foods provided in excess of those listed
on the voucher.
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives. 7. Prices not marked clearly on WIC food items or near WIC food items. 8. Allowing WIC food items to exceed the quantity specified on the voucher. (Except
for promotional or free items) 9. Failure to allow the purchase of any WIC food item(s). 10. Issuing rain checks/IOU's for WIC approved foods. 11. Failure to provide the WIC Program with any changes in vendor info within 21
days of the date that the change is to take place. (Pertaining to but not limited to name changes, corporate structure, sell or transfer, change of location etc...) 12. Fourth offense rendering a termination for cause following the third assessment of a civil money penalty (This Sanction is subject to an Abbreviated Administrative Review only). .
Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of receiving, transacting, and/or redeeming food vouchers in locations
different from the authorized location listed on the Agreement including the use of an unauthorized vendor and/or an unauthorized person, this includes but is not limited to delivering WIC food items to WIC participants and collecting WIC vouchers prior to completing the WIC transaction(s). 2. A pattern of providing credit or non-food items in exchange for WIC vouchers. 3. A pattern of overcharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WIC participant more for food than a non-WIC customer) during a compliance investigation. 4. A pattern of charging for supplemental foods not received by the participant, this includes but is not limited to vendor representatives receiving WIC foods omitted by the participants. The WIC participant(s) does not have the authority to give WIC foods to vendor or its representatives and neither the vendor or its representatives shall accept such WIC food items.

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5. A pattern of claiming reimbursement for the sale of an amount of a specific supplemental food item which exceeds the store's documented inventory of that supplemental food item for a specific period of time.
6. One incidence of the sale of alcohol or alcoholic beverages or tobacco products in exchange for WIC vouchers.
C. Any violation from category VI or VII that occurs at any time will result in immediate disqualification for the period specified in category VI & VII.
Category VI - Disqualification for six (6) years (seventy-two months) for each violation.
Mandatory Sanctions Violations: 1. One incidence of buying or selling WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.
Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)].
Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for buying or selling WIC vouchers for firearms. 3. Conviction for buying or selling WIC vouchers for ammunition. 4. Conviction for buying or selling WIC vouchers for explosives. 5. Conviction for buying or selling WIC vouchers for controlled substances.
XIV. Restrictions in Vendor Incentive Items

The vendor agrees and covenants: 1. To not provide transportation for the WIC customer to or from vendor's premises.
2. To not deliver WIC approved foods to the WIC customer's residence.
3. To not offer incentive items to the WIC customer in exchange for patronization.

XV. SPECIAL CERTIFICATION
The vendor acknowledges, understands and accepts, through the signature of the owner, or an authorized representative below, that he or she understands and accepts all terms of this agreement. The individual signing this agreement certifies that they are authorized to sign the agreement on behalf of the vendor.
This agreement becomes valid only upon the signature of an authorized representative of the Georgia WIC Program and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

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VENDOR SIGNATURE

Signature of Authorized

First

Representative (no initials)

Authorized Representative First (Type or Print) (no initials)

Title (Type or Print)

Middle

Last

Middle

Last

DO NOT WRITE BELOW THIS LINE GEORGIA WIC PROGRAM USE ONLY GEORGIA WIC PROGRAM SIGNATURE

Date Date

Signature Authorized Representative (Type or Print) Title (Type or Print)

Date

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GEORGIA WIC PROGRAM
WIC VENDOR AGREEMENT

Attachment VM-5

Full Legal Name of Store or Corporation
Doing Business As (If applicable)
Street Address
Store location or corporate home office

City Business Telephone

(Area Code)

State
Number

Mailing Address
If different from above. All communications, i.e. disqualifications, sanctions, addendums, annual training, etc. will be mailed to the location listed here.

City

State

Email Address

Fax Number

Federal Employer Identification Number

Registered Agent

Mailing Address
Disqualifications and terminations will be mailed to this address

City

State

DO NOT WRITE BELOW THIS LINE GEORGIA WIC PROGRAM USE ONLY

Zip County
Zip
Zip

See Attached Spreadsheet
This Agreement is by and between the Georgia Women, Infant and Children Program, hereinafter known as the "Georgia WIC Program," having a mailing address of Two Peachtree Street NW, Suite 10-476, Atlanta, Georgia, 30303-3142, and the above named vendor hereinafter known as "the Vendor." This agreement is effective for the period beginning ______________________________ and ending September 30, 2011.

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I.

PURPOSE

The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed nutritious supplemental foods in accordance with federal laws and regulations and the Georgia Nutrition Program for Women, Infants and Children (WIC) pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.

II. VENDOR ELIGIBILITY AND LOCATION

A. An eligible vendor is a business entity that is 1) licensed by the Georgia Department of Agriculture and, 2) without a debarment or suspension from United States Department of Agriculture. Military commissaries do not have to be licensed by the Georgia Department of Agriculture.

B. Effective January 1, 2010, an eligible vendor is a business entity that is 1) registered and licensed by the United States Department of Agriculture Food Nutrition Service as a retail participant in the Supplemental Nutrition Assistance Program or SNAP (formally the Food Stamp Program) and 2) is in good standing without debarment or suspension from the United States Department of Agriculture or the SNAP program. Military commissaries do not have to be SNAP participants.
C. An eligible vendor must be identified as a fixed location with an official physical address.
D. For corporate vendors owning two (2) or more locations, the requested information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement.

E. An eligible vendor must meet all requirements as described in the Georgia WIC Program Vendor Handbook and all addendums.
F. The vendor must comply with the selection criteria throughout the agreement period including any changes to the criteria. Using the current vendor selection criteria, the Georgia WIC Program may reassess the vendor at any time during the agreement period. The Georgia WIC Program will terminate the Vendor Agreement if the vendor fails to meet the current vendor selection criteria at reassessment.
G. An eligible vendor, authorized as a military commissary, pharmacy or corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in the Georgia WIC Program Vendor Handbook and all addendums.

III. RESPONSIBILITIES VENDOR

The Vendor agrees to adhere to all federal and state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration and any subsequent revisions to the policies, procedures, laws, rules and regulations issued by the federal government and/or the Georgia WIC Program. This Agreement will be interpreted based on the laws of the State of Georgia.

A. The vendor agrees and covenants: 1. To be fully accountable for the actions of its paid or unpaid owners, officers, managers, agents and employees.

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2. To abide by the rules, policies and procedures as outlined in the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums.
3. To not solicit the WIC customer on the premises of WIC clinics. 4. To solely purchase infant formula, that will be redeemed for WIC vouchers,
from the Approved Infant Formula Supplier list. If a supplier is not listed, a vendor is required to call 866-814-5468 or 404-657-2900 to inquire about adding them to the list. The vendor must ensure that the requested supplier has been authorized by the Georgia WIC Program, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained according to Section III.I.3 of this Agreement. 5. To submit total food sales and gross sales revenue records, as requested, by Georgia WIC Program. 6. To immediately notify the Georgia WIC Program when greater than 50% of total food sales revenue is derived from the redemption of WIC vouchers. 7. To not use the WIC logo or acronym, including close facsimiles thereof, in total or in part, either in the name in which the vendor is registered or under the name in which it does business, or in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program including such wording as, but not limited to, "WIC Only". 8. To carry a substantial amount of non-WIC food inventory at all times.

B. VENDOR TRAINING
Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The Georgia WIC Program will provide the date, time and location of the training. The vendor may submit a written request, for the Georgia WIC Program to provide subsequent customized training to store personnel at anytime after both parties have signed the agreement.
The vendor agrees and covenants:
1. To provide training to paid and unpaid employees, agents and all personnel involved in WIC transactions.
2. To not participate in the Georgia WIC Program until Authorized Training has been completed and a vendor stamp has been issued.
3. To not participate until the vendor has received a passing score of eighty (80) points or above on the Post Vendor Training Evaluation.
4. To provide documentation that a management representative(s) from each location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (Form 3757A), (Corporate vendors only).

C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES
The vendor agrees and covenants:
1. To only charge for authorized supplemental foods selected by the WIC customer as listed on the food voucher or cash value/fruit and vegetable voucher and not charge for WIC approved items that are not received.
2. To not provide unauthorized food items, non-food items or cash in exchange for food vouchers or cash value/fruit and vegetable voucher.
3. To not provide refunds or permit exchanges for authorized supplemental food vouchers except for exchanges of the same brand and size authorized supplemental food item when the original authorized supplemental food item

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is defective, spoiled, recalled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.

D. FOOD VOUCHER TRANSACTIONS
The vendor agrees and covenants:
1. To not accept WIC food vouchers or cash value/fruit and vegetable vouchers before the "First Date to Use" or after the "Last Date to Use" as printed on the voucher.
2. To submit vouchers to the bank for payment within sixty (60) days from the "First Date to Use" as indicated on each voucher.
3. To assure that WIC food voucher transactions are processed in accordance with the procedures set forth in the recent Georgia WIC Program Vendor Handbook and all addendums.
4. To not demand that a WIC Participant, caretaker and or proxy, hereafter called the WIC customer, purchase every eligible WIC food item listed on the voucher.
5. To allow WIC customers the right to purchase the eligible foods of their choice as listed on the WIC food voucher, cash value/fruit and vegetable voucher and the approved food list.
6. To only allow the purchase of supplemental foods listed on the food voucher and cash value/fruit and vegetable voucher.
7. To ensure that the Georgia WIC Program is not being charged for foods not received by the participant.
8. To not transfer Georgia WIC Program vouchers from vendor to vendor. 9. To not accept Georgia WIC Program vouchers from another vendor for
payment. 10. To not accept WIC vouchers or cash value/fruit and vegetable vouchers in an
unauthorized location for payment in an authorized location. 11. To not contact or seek restitution from the WIC customer for WIC food
vouchers not paid or partially paid by the Georgia WIC Program. 12. To not request cash from the WIC customer for any WIC transaction except
for transactions involving the cash value/fruit and vegetable voucher. 13. To not provide the WIC customer with rain checks/IOU's, credit slips, due bills
or other similar receipts for WIC foods not obtained at the time of the purchase. 14. To allow WIC customer to participate in in-store and/or manufacturer promotions that include WIC approved food items. This includes buy one, get one or more free. 15. To not collect sales tax on prescribed WIC food purchases. 16. To not charge the WIC customer or the WIC Program for bank fees or other fees related to voucher redemption. 17. To advise the WIC customer that the Georgia WIC Program is not responsible for the home delivery of food items or any other in-store promotions. 18. To insert, in ink the actual cost (shelf price) of the WIC foods in the "Pay exactly box" at the time of purchase in the presence of the customer, prior to obtaining a signature. 19. To not provide unauthorized food, or non-credit food items, cash, credit (including rain checks) in exchange for food vouchers and cash value/fruit and vegetable vouchers. 20. To include sales tax for the difference over the amount on the face of the cash vaule fruit and vegetable voucher.

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21. To allow the WIC customer to use his/her own funds in excess of the monetary limits for his/her cash value/fruit and vegetable voucher.
22. To not issue cash change to a WIC customer for purchases less than the total value of the cash value/fruit and vegetable voucher
23. To only use the cash value/fruit and vegetable voucher for fruit and vegetable purchases.

E. PRICING
The vendor agrees and covenants:
1. To clearly mark the price of WIC foods on the item, container, shelf or sign. 2. To provide each WIC food item at or below the current shelf price. 3. To accept an adjustment in the amount written in the pay exactly box of the
WIC voucher. The amount to be paid will be based upon the average voucher redemption which will be based upon the average voucher(s) redemption for all comparable stores in the same peer group and/or the statewide average for a given time period.

F. OVERCHARGING

The vendor agrees and covenants:
1. To not overcharge the WIC customer or the Georgia WIC Program by charging more than the vendor's current shelf price for a WIC approved food item(s), or charging a WIC participant more for food than a non WIC customer. (Overcharging is considered a violation and will result in sanction(s) if it occurs during a covert investigation.

G. VENDOR COST CONTAINMENT

Vendor Cost Containment is intended to assist state agencies in achieving compliance with section 17(h)(11) of the Child Nutrition Act of 1966 (CNA), as amended by the Child Nutrition and WIC Reauthorization Act of 2004 (Public Law 108-265).

The New requirements underscore the State agency's responsibility to ensure that the program pays all vendors competitive prices for supplemental foods. The State WIC Program implemented a cost containment plan to identify and manage vendors who derive more than 50 percent of their annual food revenue from WIC food instruments.
By June 30th of each year the State WIC Program will assess each vendor as to if they derive more than 50 percent of their food revenue from WIC food instruments annually and new vendors six months after enrollment.

The State WIC Program utilizes a methodology that uses redemption data to determine the maximum allowable reimbursement levels (MARL) for food instruments.

H. CIVIL RIGHTS
The vendor agrees and covenants: 1. To abide by the United States Civil Rights Act and the United States Civil
Rights Policy Statement and to assure that discrimination is prohibited

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towards WIC customers and all related activities, on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital status. 2. To offer the WIC customer the same courtesies offered to all other customers. 3. To display the "We Welcome WIC'' poster provided by the Georgia WIC Program on the door glass or other prominent place. 4. To assure that all information, including the identity of the WIC customer is kept confidential in accordance with state and federal law.

I.

CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION

The vendor agrees and covenants:
1. To submit, upon request, to the Georgia WIC Program a copy of all acceptable proof of ownership, identity and related documents, (e.g. articles of incorporation, bill of sale and partnership declaration and evidence of sole proprietorship, social security card, driver's license, etc.)
2. To notify the Georgia WIC Program in writing at least twenty-one (21) days in advance if the vendor plans to cease business operation, change ownership, store name or move from the authorized location.

J. PERFORMANCE COMPLIANCE AND CONFLICT OF INTEREST
The vendor agrees and covenants:
1. To permit unannounced visits by federal or state agency representatives to review adherence to federal laws and to the Georgia WIC Program's policies and procedures.
2. To provide access to WIC food vouchers and/or cash value/fruit and vegetable vouchers on hand, inventory records (invoices) and any other business records during a monitoring visit or inventory audit by an authorized federal or state agency representative.
3. To maintain required records for four years or until pending investigations are adjudicated.
4. To disclose any potential or actual conflict of interest between the vendor and Georgia WIC Program employees.
5. To not permit its' paid or unpaid owners, officers, managers, agents and employees to conduct with the WIC customer, any conflict of interest activities or similar acts, as determined by the Georgia WIC Program. This includes, but is not limited to instances where an authorized WIC vendor acts as a proxy for the WIC customer.
6. To not attempt to circumvent a sanction(s) by selling assigning or otherwise transferring ownership to the vendor's partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns.
7. To not use the WIC logo or acronym, including close facsimiles thereof, in total or in part, either in the name in which the vendor is registered or under the name in which it does business, or in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program including such wording as, but not limited to, "WIC Only".

K. VENDOR SANCTION SYSTEM AND VENDOR CLAIMS The vendor agrees and covenants:

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1. To pay claims and penalties levied for audit citations and for sanctions levied pursuant to this agreement and the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums.
2. That the Georgia WIC Program can impose claims, sanctions and penalties as outlined in this agreement and the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums.

L. STATE PROPERTY
The vendor agrees and covenants:
1. To return the vendor stamp(s) to the Georgia WIC Program upon termination, change of ownership or disqualification.
2. To report lost, stolen or damaged vendor stamps to the Georgia WIC Program immediately.

IV. RESPONSIBILITIES GEORGIA WIC PROGRAM

The Georgia WIC Program agrees to adhere to federal and/or state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration.

Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to the Georgia WIC Program issued by the federal government are hereby made a part of this agreement.

The Georgia WIC Program further agrees to the following:

A. To supply the vendor with the most recent publication of the Georgia WIC

Program Vendor Handbook and all addendums.

B. To assure that the WIC customer are informed of the proper voucher redemption

procedures and the correct use of WIC vouchers.

C. To assure that vouchers are provided to qualified women, infants and children.

D. To notify the vendor of new requirements as set forth by the U.S. Department of

Agriculture's regulations and/or the Georgia WIC Program's policies and

procedures.

E. To provide training for the vendor on policies and procedures of the WIC

Program, at a time, place and in a manner prescribed by the Georgia WIC

Program.

F. To monitor and audit the vendors for possible violations of the Georgia WIC

Program rules, regulations, policies or procedures.

G. To enforce rules, regulations, policies and procedures of the Georgia WIC

Program through a system of claims, penalties, and/or sanctions against the

vendor as described in the most recent publication of the Georgia WIC Program

Vendor Handbook and all addendums.

H. To provide an appropriate written notice of intent or reason(s) to terminate this

agreement.

I.

To notify the vendor of the right to appeal adverse actions.

J. To provide payment for vouchers validly redeemed and submitted to the Georgia

WIC Program as prescribed in the most recent publication of the Georgia WIC

Vendor Handbook and all addendums.

K. To deny payment for vouchers improperly completed, redeemed or submitted in

accordance with the most recent publication of the Georgia WIC Program Vendor

Handbook and all addendums.

L. To refuse authorization to a vendor applicant if it is determined that the store(s) is

being sold in an attempt to circumvent a Georgia WIC Program sanction.

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M. To notify vendor of stolen vouchers. The stolen vouchers may not be redeemed. N. To maintain an up to date listing of Approved Infant Formula retailers,
wholesalers, manufactures and distributors, which authorized vendors must use to purchase infant formula and to approve additional suppliers upon request.

V. RENEWABILITY

This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the current agreement period, the vendor must reapply for authorization.

VI. NON TRANSFERABILITY

This agreement is not transferable.

VII. EXPIRATION, TERMINATION AND DISQUALIFICATION

A. Expiration of this agreement is not subject to appeal by the vendor. B. Either party may terminate the agreement. C. The Georgia WIC Program may terminate for cause, after providing the vendor a
twenty-one (21) day advance written notice. Vendors have the right to request an Administrative Review. D. Disqualification is an adverse action taken by the Georgia WIC Program and is based on the sanction system outlined in the Georgia WIC Program Vendor Handbook and all addendums.

VIII. ADVERSE ACTIONS AND REVIEW PROCEDURES

1. A vendor may request an Administrative Review for the following:

A. Denial of authorization based on the vendor selection criteria for competitive

price or for minimum variety and quantity of authorized supplemental foods or the

determination that the vendor is attempting to circumvent a sanction.

B. Disqualification.

C. Imposition of a civil money penalty in lieu of disqualification.

D. Denial of authorization based on the vendor selection criteria for business

integrity or for a current SNAP disqualification or civil money penalty for hardship.

E. Denial of authorization because a vendor submitted its application outside the

established timeframes, August 1 September 30 of each year.

F. Disqualification based on a trafficking conviction.

G. Disqualification based on the imposition of a SNAP Civil Money Penalty for

hardship in lieu of disqualification.

H. Termination for cause including, but not limited to, the violation of any federal

regulation not otherwise covered in the sanction system.

I.

Denial of authorization based on the determination that an applicant purchased

infant formula, which will be redeemed with WIC vouchers, from an unapproved

infant formula supplier which was not listed on the Approved Infant Formula List.

J. Denial of authorization based on the determination that an applicant is expected

to derive more than 50% of its' annual food revenue from the sale of WIC

vouchers.

Administrative Review Procedures are outlined in the most recent Georgia WIC Vendor Handbook.

Revised 7/2009

VM-78

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-5 (cont'd)

2. A vendor may request an Abbreviated Administrative Review for the following Termination for Cause reasons:

A. Use of the WIC acronym or WIC logo, including close facsimiles thereof, in total or in part , either in the official name in which the vendor is registered or in the name under which it does business, if different.
B. Pharmacy vendors shall not accept vouchers through the mail, nor mail any approved formula/medical foods directly to the WIC customer.
C. Failure to complete and submit documentation for annual training by the deadline specified by the Georgia WIC Program.
D. Failure to inform the Georgia WIC Program of a change in ownership or cessation of operation within at least 21 days of change and the effective date.
E. Termination for cause for 60 days, including but not limited to the violation of any federal regulation or terms of the WIC vendor agreement not otherwise covered by the sanction system.
F. Failure to submit or return requested documentation or information by any stated deadline.
Vendors terminated for Above 50% status can request an Abbreviated Administrative Review.

Abreviated Administrative Review Procedures are outlined in the most recent Georgia WIC Vendor handbook.

IX. Termination for Cause

A. The Georgia WIC Program may penalize the vendor by terminating the vendor for cause in accordance with the procedure prescribed in the most recent publication of the Georgia WIC Vendor Handbook and addendums.

B. A written notification of the termination shall be mailed to the affected party at least twenty-one (21) calendar days in advance. At the end of the period stated in the 21 day notice, the vendor will be terminated.

C. At the end of the termination period, the vendor will not be automatically reinstated. The Vendor will have to re-apply.

D. Effective January 1, 2010, in lieu of termination for cause, or for vendors in areas of inadequate participant access, the Georgia WIC Program will allow vendors to pay a minimum of a $1000.00 Civil Money Penalty and be reinstated immediately. In instances of termination for cause for non-submission of requested documentation, the vendor must pay the penalty and submit the requested documentation. The amount to be paid will be based on the severity of the offense. Subsequent offenses rendering a termination for cause, up to the third termination for cause, will be subject to an increase in Civil Money Penalties.

E. Effective January 1, 2010, after the third offense rendering a termination for cause, the vendor will be subjected to disqualification under a Category IV Sanction.

F. Effective January 1, 2010, after the third offense for vendors in areas of inadequate participant access, the vendor will be subject to the Civil Money Penalty schedule for a Category IV sanction.

Revised 7/2009

VM-79

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-5 (cont'd)

X. PENALTIES
A. The Georgia WIC Program may penalize the vendor by issuing sanctions in accordance with the procedures prescribed in the most recent publication of the Georgia WIC Vendor Handbook and all addendums. The Georgia WIC Program sanctions may include disqualification, warnings, probation and civil money penalties in lieu of disqualification. The State agency will provide the vendor with prior warning about violations before imposing such sanctions (7CFR 246.12 XVIII), except when notification would compromise the investigation.
B. A vendor maybe subject to criminal penalties as a result of a violation of the Georgia WIC Program in addition to civil money penalties described above. Vendors who have willfully misapplied, stolen or fraudulently obtained WIC funds shall be subject to a fine of not more than $25,000.00 imprisonment for not more than five (5) years or both. If the value of the funds is less than $100.00 then the penalties may be a fine of not more than $1,000.00, imprisonment for not more than one (1) year or both.
C. If a disqualification for a mandatory sanction is not upheld during the administrative review process, then the remaining State Agency Sanction(s), if any, will remain on the vendor's record for one year.
D. Vendors will be subject to reimbursement of food instruments beginning with date of disqualification and through and until the administrative review and appeals process is complete.

XI. SEVERABILITY

If any one provision of this agreement or form attached to or incorporated by reference is waived or held to be invalid, such waiver or invalidity shall not affect other provisions of this agreement.

XII. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS

A. Sanctions - any sanction(s) that are in the vendor's record at the time of reauthorization will remain on the vendor's record for the period of time specified when the sanction was issued. Prior year's sanctions may result in a denial of the authorization of the application and/or additional sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.
B. Violations - Pending and/or potential violations, that exists at the time of reauthorization will accrue and will result in sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.

XIII. SANCTION SYSTEM

Following is a description of the Georgia WIC Program Sanction System and how it is implemented. Civil Money Penalties (CMP) may be assessed in Categories I-IV in

Revised 7/2009

VM-80

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-5 (cont'd)

lieu of disqualification for State Agency sanctions only. CMP's shall only be assessed for mandatory sanctions listed in Category IV and Category V if the disqualification results in inadequate participant access. Vendor violations will be categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall determine the period of probation and disqualification. Disqualification from the WIC program may also result in disqualification from the SNAP Program.

A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item(s) outside of manufacturer's expiration date(s). 2. Charging sales tax on WIC food item(s) other than those purchased with a cash
value/fruit and vegetable voucher. 3. Failure to allow in-store or manufacturers' promotional or free item(s) with a WIC
purchase. 4. Failure to provide WIC participants with a receipt 5. Failure to check the WIC participants and/or proxy WIC ID card.

Category II - Warning on first offense, second offense-probation for eight (8) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to ring up sales of WIC purchases. 2. Failure to write the price on voucher before the participant signs. 3. Failure to stock the required inventory of contract formula. 4. Failure to stock the required inventory of two or more WIC food items. 5. Refusing to accept valid WIC vouchers from participants. 6. Allowing the substitution of one WIC approved food item listed on the voucher for
another WIC approved food item not listed on the voucher. 7. Allowing the purchase of WIC foods in unauthorized container sizes. 8. Failure to remain open for business at least eight hours per day, six days per week. 9. Failure to repay charges within thirty (30) days.
Category III - Warning on first offense, second offense - probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Contacting WIC participants for any reason regarding a WIC transaction. 2. Requiring participant to pay cash to redeem WIC vouchers, with an exception of cash
value/fruit and vegetable vouchers. 3. Allowing the purchase of any formula other than the one specified on the front of the
voucher. 4. Providing incentive items as part of the WIC transaction. 5. One occurrence during a compliance investigation of a violation in Category IV,
violations 1-2. 6. One occurrence during a compliance investigation of a violation in Category V, violations
1-5.

Revised 7/2009

VM-81

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-5 (cont'd)

7. Requiring WIC Participants to show any identification other than the WIC Identification Card.

B. Any violation from category IV or V that occurs at any time will result in immediate disqualification for the period specified in each category. A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year (twelve months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC vouchers. 2. A pattern of charging for supplemental foods provided in excess of those listed on the
voucher.
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives. 7. Prices not marked clearly on WIC food items or near WIC food items. 8. Allowing WIC food items to exceed the quantity specified on the voucher. (Except for
promotional or free items) 9. Failure to allow the purchase of any WIC food item(s). 10. Issuing rain checks/IOU's for WIC approved foods. 11. Failure to provide the WIC Program with any changes in vendor info within 21 days of
the date that the change is to take place. (Pertaining to but not limited to name changes, corporate structure, sell or transfer, change of location etc...) 12. Fourth offense rendering a termination for cause following the third assessment of a civil money penalty (This Sanction is subject to an Abbreviated Administrative Review only). .
Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of receiving, transacting, and/or redeeming food vouchers in locations different
from the authorized location listed on the Agreement including the use of an unauthorized vendor and/or an unauthorized person, this includes but is not limited to delivering WIC food items to WIC participants and collecting WIC vouchers prior to completing the WIC transaction(s). 2. A pattern of providing credit or non-food items in exchange for WIC vouchers. 3. A pattern of overcharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WIC participant more for food than a non-WIC customer) during a compliance investigation. 4. A pattern of charging for supplemental foods not received by the participant, this includes but is not limited to vendor representatives receiving WIC foods omitted by the participants. The WIC participant(s) does not have the authority to give WIC foods to vendor or its representatives and neither the vendor or its representatives shall accept such WIC food items. 5. A pattern of claiming reimbursement for the sale of an amount of a specific supplemental food item which exceeds the store's documented inventory of that supplemental food item for a specific period of time.

Revised 7/2009

VM-82

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-5 (cont'd)

6. One incidence of the sale of alcohol or alcoholic beverages or tobacco products in exchange for WIC vouchers.
C. Any violation from category VI or VII that occurs at any time will result in immediate disqualification for the period specified in category VI & VII.
Category VI - Disqualification for six (6) years (seventy-two months) for each violation.
Mandatory Sanctions Violations: 1. One incidence of buying or selling WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.
Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)].
Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for buying or selling WIC vouchers for firearms. 3. Conviction for buying or selling WIC vouchers for ammunition. 4. Conviction for buying or selling WIC vouchers for explosives. 5. Conviction for buying or selling WIC vouchers for controlled substances.

XIV. Restrictions in Vendor Incentive Items The vendor agrees and covenants: 1. To not provide transportation for the WIC customer to or from vendor's premises. 2. To not deliver WIC approved foods to the WIC customer's residence. 3. To not offer incentive items to the WIC customer in exchange for patronization.
XV. SPECIAL CERTIFICATION
The vendor acknowledges, understands and accepts, through the signature of the owner, or an authorized representative below, that he or she understands and accepts all terms of this agreement. The individual signing this agreement certifies that they are authorized to sign the agreement on behalf of the vendor.
This agreement becomes valid only upon the signature of an authorized representative of the Georgia WIC Program and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

VENDOR SIGNATURE

Signature of Authorized

First

Representative (no initials)

Authorized Representative First

Revised 7/2009

Middle

Last

Middle
VM-83

Last

Date Date

GA WIC 2010 PROCEDURES MANUAL (Type or Print) (no initials) Title (Type or Print)

Attachment VM-5 (cont'd)

DO NOT WRITE BELOW THIS LINE GEORGIA WIC PROGRAM USE ONLY
GEORGIA WIC PROGRAM SIGNATURE

Signature Authorized Representative (Type or Print) Title (Type or Print)

Date

Revised 7/2009

VM-84

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-6

GEORGIA WIC PROGRAM CORPORATE ATTACHMENT FORM

FOR GEORGIA WIC Program (GWP) USE ONLY

District/Unit

Date Received

Date Approved QAS:

Date Denied

QAS:

Reason Denied

Processed By

Vendor Number

VM:

VD:

VM:

VD:

Peer Group

A. Is this store expected to derive more than 50% of its annual food sales from the sale of WIC approved foods? (Food sales mean foods that are eligible items under the SNAP Program.)

Yes

No

B. Is this form submitted due to a change in the store's location?

Yes

No

Full Legal Name of Corporation Full Legal Name of Store

STORE IDENTIFICATION
Store Number

WIC Vendor No.

Address

County

City

State

Zip

Business Telephone
Mailing Address
(If Different From Above)

(Area Code)

Number

Fax County

(Area Code) Number

City

State

Zip

Store Contact and Title
E-mail Address (Required)

Name LICENSING

Title
Square Footage of Store
(including storage area)

Federal Employer Identification Number

Food Stamp Authorization Number (Required For Approval)

Food Sales Establishment License Number

Date store representative received WIC Authorization Training (Form #3757A Corporate Training Checklist is required as documentation.)

VM-85

FORM 3771A (04/09)

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

INVENTORY AND PRICE LIST

Date store will open(ed)

Number of Cash Registers

Number or Scanners

Can scanners detect WIC eligible foods?

Yes

No

Does this store have a point of sale device?

Yes

No

Food Item

Brand Name

1.

Juice

2.

Cereal

3.

Peas/Beans

Peas/Beans

4. Peanut Butter

Infant Cereal

5.

Rice

Similac Advance Early Shield 6. w/Iron
Similac Advance Early Shield w/Iron (Powder)
7. Isomil Advance w/Iron
Isomil Advance w/Iron (Powder) Whole Pasteurized 8. Milk 2%, 1% or Skim 9. Milk 10. Dry Milk

11. Cheese
12. Eggs (Large Only) 13. Fresh Fruit 14. Fresh Vegetables 15. Bread
Fish Tuna or 16. Salmon
Baby Food Fruits 17. and vegetables 18. Baby Food Meats

Size

Highest Price or

Least Expensive

where indicated

46-48 oz. bottle 64 oz. plastic bottle 11 to 36 oz. box 1 pound bag 14-16 oz cans 18 oz. jar

8 oz. box 13 oz. can concentrate

On-Site Price

12.9 oz. can
13 oz. can concentrate
12.9 oz. can
1 gallon container
(Least Expensive)
1 gallon container
(Least Expensive)
Makes 3 quarts
1 pound package
(Least Expensive)
1 dozen carton
(Least Expensive)
10 pounds 10 pounds 16 oz. loaf 5-6 oz. can

4 oz. jar 2.5 oz. jar

VM-86

FORM 3771A (04/09)

GA WIC 2010 PROCEDURES MANUAL

Food Item
19. Juice 20. Juice

Brands (B)
Types (T) 2 (T)
2 (T)

Size
46 oz. 64 oz.

Attachment VM-6 (cont'd)

Item In

Stock?

Yes

No

Yes

No

Minimum Quantity In Stock?

12

Yes

No

12

Yes

No

Cereal

4 (T) 11 to 36 oz. Yes

No

24

21. (2 types must be Whole Grain)

Yes

No

22. Dried Peas/Beans 23. Canned Peas/Beans

2 (T) 1 lb. pkg. Yes

No

5

2 (T) 14-16 oz. Yes

No

18

Yes

No

Yes

No

Peanut Butter 24.
Infant Cereal 25. (1 type must be rice)

2 (B)

18 oz.

Yes

No

6

2 (T)

8 oz.

Yes

No

12

Yes

No

Yes

No

Yes

No

Yes

No

26. Similac Advance Early Shield

1 (B)

13 oz.

Yes

No

62

w/Iron

27. Similac Advance Early Shield

1 (B)

12.9 oz Yes

No

30

Powder w/Iron

28. Isomil Advance w/Iron

1 (B)

13 oz.

Yes

No

31

29. Isomil Advance Powder w/Iron 1 (B)

12.9 oz Yes

No

15

Yes

No

Yes

No

Yes

No

Yes

No

30. Pasteurized Milk - whole

1 (B) 1 gallon

Yes

No

12

Yes

No

31. Pasteurized Milk 2%, 1% or

1 (B) 1 gallon

Yes

No

18

skim

Yes

No

32. Dry Milk non-fat

1 (B) Makes 3 qt. Yes

No 3 boxes

Yes

No

33. Cheese

2 (T) 1 pound

Yes

No

8

Yes

No

34. Eggs (Large Only) 35. Bread 36. Fruit 37. Vegetables 38. Fish (Tuna or Salmon)
39. Baby Food Fruits 40. Baby Food Vegetable 41. Baby Food Meat

1 (B) 1 dozen

Yes

No

8

Yes

No

1 (B) 16 oz. loaf Yes

No

6

Yes

No

4 (T) 10 pounds Yes

No 10 lbs.

Yes

No

4 (T) 10 pounds Yes

No 10 lbs.

Yes

No

1 (T) 5-14.75 oz. Yes

No

18

Yes

No

can

2 (T)

4 oz.

Yes

No

96

Yes

No

2 (T)

4 oz.

Yes

No combined

Yes

No

2 (T)

2.5 oz.

Yes

No

31

Yes

No

VM-87

FORM 3771A (04/09)

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

STORE OPERATIONS

A. Were all infant formula, that will be used to redeem WIC vouchers, purchased from suppliers listed on the Approved Infant Formula Supplier List? (See www.health.state.ga.us/programs/WIC/vendorinfo.asp)

Yes

No

Note: Records of all infant formula purchases must be maintained according to the terms of the WIC Vendor Agreement, III, I.3.

Supplier

Address

City

State

Supplier

Address

City

State

Supplier

Address

City B. Hours of Business

Open 24 Hours

State

Sunday

Thursday

Monday

Friday

Tuesday

Saturday

Wednesday

Signature of Authorized Representative Authorized Representative (Type or Print)
Telephone Number

Date Title (Type or Print)

VM-88

FORM 3771A (04/09)

GA WIC 2010 PROCEDURES MANUAL

Please print all information.
STORE NAME & NUMBER

Georgia WIC Program VENDOR TRAINING CHECKLIST
AUTHORIZED TRAINING
VENDOR NUMBER

I have been trained on and I understand:

Attachment VM-7

1. The purpose of the Georgia WIC Program and how to contact the Georgia WIC Program.

2. Terms of the Vendor Agreement. The agreement is null and void upon change of ownership. The vendor must re-apply to continue as a vendor upon expiration of agreement.

3. The responsibility of adhering to the selection criteria throughout the agreement period. This includes but is not limited to: a. Stocking a minimum quantity and variety of approved WIC foods daily. b. Stocking a substantial amount of non-WIC food inventory daily. c. Prices compatible to stores in same peer group. d. Compliance with Supplemental Nutrition Assistance Program (formally the Food Stamp Program) regulations. e. Business integrity
4. The purpose of vendor training and the requirement to attending training. The vendor is responsible for training its employees on the information discussed at training. The vendor is responsible for the actions of its officers, managers, agents and paid or unpaid employees.
5. The WIC approved food items and the requirement to stock and maintain the minimum inventory of approved WIC food items and non-WIC food items on a daily basis.

6. The types of valid WIC vouchers and the procedures for transacting Georgia WIC vouchers.
7. The requirement to enroll in the Automatic Clearing House (ACH) following authorization to the Georgia WIC Program.
8. The procedures for redeeming Georgia WIC vouchers/Cash Value Fruit and Vegetable Vouchers (CVFVV) and the use of the vendor stamp.

9. Returned voucher payment procedures and the provision for the Georgia WIC Program to make price adjustments.

10. The responsibility of the vendor to be in compliance with the review of the store via overt monitoring, audits, covert investigations and analyses of programmatic reports.

11. Violations of program and applicable sanctions, including the federally mandated sanctions, disqualification periods, and civil money penalties. Disqualifications from the Georgia WIC Program may result in disqualification from the SNAP Program.
12. The right to request an administrative review for adverse action(s) taken against the vendor.

I ACKNOWLEDGE THAT I HAVE BEEN TRAINED ON THE ITEMS LISTED ABOVE AND RECEIVED A CURRENT GEORGIA WIC VENDOR HANDBOOK.

Signature of Store Representative

Date

Print Name Form 3757 (Rev. 07-09)

Title VM-89

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-8

Georgia WIC Program CORPORATE VENDOR TRAINING CHECKLIST Please print all information. CORPORATE VENDOR NAME

STORE NAME & NUMBER

VENDOR NUMBER

I have been trained on and I understand:

1. The purpose of the Georgia WIC Program and how to contact the Georgia WIC Program.

2. Terms of the Vendor Agreement. The agreement is null and void upon change of ownership. The vendor must re-apply to continue as a vendor upon expiration of agreement.

3. The responsibility of adhering to the selection criteria throughout the agreement period. This includes but is not limited to: a. Stocking a minimum quantity and variety of approved WIC foods daily. b. Stocking a substantial amount of non-WIC food inventory daily. c. Prices compatible to stores in same peer group. d. Compliance with Supplemental Nutrition Assistance Program (formally the Food Stamp Program) regulations. e. Business integrity

4. The purpose of vendor training and the requirement to attending training. The vendor is responsible for training its employees on the information discussed at training. The vendor is responsible for the actions of its officers, managers, agents and paid or unpaid employees.

5. The WIC approved food items and the requirement to stock and maintain the minimum inventory of approved WIC food items and non-WIC food items on a daily basis.

6. The types of valid WIC vouchers and the procedures for transacting Georgia WIC vouchers.

7. The requirement to enroll in the Automatic Clearing House (ACH) following authorization to the Georgia WIC Program.

8. The procedures for redeeming Georgia WIC vouchers/Cash Value Fruit and Vegetable Vouchers (CVFVV) and the use of the vendor stamp.

9. Returned voucher payment procedures and the provision for the Georgia WIC Program to make price adjustments.

10. The responsibility of the vendor to be in compliance with the review of the store via overt monitoring, audits, covert investigations and analyses of programmatic reports.

11. Violations of program and applicable sanctions, including the federally mandated sanctions, disqualification periods, and civil money penalties. Disqualifications from the Georgia WIC Program may result in disqualification from the SNAP Program.

12. The right to request an administrative review for adverse action(s) taken against the vendor.

I ACKNOWLEDGE THAT I HAVE BEEN TRAINED ON THE ITEMS LISTED ABOVE AND RECEIVED A CURRENT GEORGIA WIC VENDOR HANDBOOK.

Signature of Store Representative

Date

Print Name
Form 3757A (Rev. 07/2009)

Title VM-90

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-8

Form 3757A (Rev. 07/2009)

VM-91

GA WIC 2010 PROCEDURES MANUAL

District/Unit/Clinic: County: Date of Incident: Date Reported: Follow-up Date:

GEORGIA DEPARTMENT OF HUMAN RESOURCES
WIC PROGRAM INCIDENT/COMPLAINT FORM

Person Filing Complaint Name: Address:
Phone: Local Agency Resolution:

Participant Information Name: Guardian:
WIC I.D. Number: DOB: Phone:

Vendor Information Vendor/Vendor#: Employee's Name:
Title: Phone:

Georgia WIC Branch Resolution/Comments:

Follow-Up Report: GWB Customer Service Coordinator:

VM-91

Attachment VM-9
Type of Complaint: Participant Vendor
Civil Rights Local Agency/Georgia WIC Branch Staff
Local Agency/State WIC Information
Staff Name: Linda Phone: Can Complaint be Closed at Local Agency? Yes No Signature and Title: Date: Can Complaint be Closed at Georgia WIC Branch? Yes No Signature and Title: Date:
Date:

GA WIC 2010 PROCEDURES MANUAL

Georgia WIC Program
VENDOR REVIEW FORM

Vendor Number

Vendor Name

District/Unit Date of Visit

Attachment VM-10

/
Month

/

Day

Year

Store Owner

Store Manager

Store Address

City

County

State

Zip

Review Type - Check One Pre-Approval

Follow-Up

Inventory Type - Check One Regular Inventory

Monitoring

Complaint

Waived Inventory

Item(s)/Qty_____________________

Minimum Inventory Requirements - Physical inventory must be in stock and within the date limit when viewed by WIC

Representative at time of visit. Proof of order of food items shall not be accepted.

Juice

Highest Price

Brand Name/Type/Size

YES

NO

1. Are there at least 12 plastic bottles or cans of 46 -48 oz. juice in stock? If no, how many? __________

2. Are there at least 12 plastic bottles of 64 oz. juice in stock? If no, how many? ________

3. Are there two flavors of juice in stock in 46 oz. cans or plastic bottles? If no, how many? _________ 4. Are there two flavors of juice in stock in 64 oz. bottles? If no, how many? ________

5. Is the price marked on juice or posted on or above the shelf/dairy case?

Cereals

Highest Price

Brand Name/Type

1. Are there at least 24 boxes of 11 oz. to 36 oz. cereal in stock? If no, how many? ___________

2. Are there at least 4 kinds of cereal in stock? If no, how many? ____________

3. Are at least 2 kinds of whole grain cereal in stock? If no, how many? _____________

4. Is the price marked on cereal or on the shelf?

5. Are all boxes WIC approved cereal within date limit? If no, how many were not? ____________

YES

NO

Peas/Beans

Highest Price

Brand Name/Type

1. Are there at least 3 16 oz. bags of peas/beans in stock? If no, how many? ________________

YES

NO

2. Are there at least 2 kinds of peas/beans in the 16 oz. package in stock? If no, how many? ___________ 3. Are there at least 12 14 to 16 oz. cans of peas/beans in stock? If no, how many? ____________

4. Are there at least 2 kinds of peas/beans in the 14 to 16 oz. cans in stock? If no, how many? _________

5. Is the price marked on the bags of peas/beans, or on the shelf?

Peanut Butter

Highest Price

Brand Name/Type

1. Are there at least 3 jars of 18 oz. peanut butter in stock? If no, how many? _______________

2. Are there at least 2 brands of peanut butter? If no, how many? ____________________

3. Is the price marked on the peanut butter or on the shelf?

YES

NO

Infant Cereal At least one type must be rice Highest Price

Brand Name/Type

1. Are there at least 12 boxes of 8 oz. infant cereal in stock? If no, how many? ____________

YES

NO

2. Is rice cereal in stock?

3. Is there one type other than rice in stock?

4. Is the priced marked on the cereal or on the shelf?

5. Are all boxes of WIC approved infant cereal within the date limit? If no, how many were not? ________

Form 3774 (Rev. 07-09) DPHP98.8HW

VM-92

Routing: White Georgia WIC Branch Yellow Vendor

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-10

Formula: Minimum 138 cans of milk based and 32 cans of soy based contract formula 1. Are there at least 62 cans of 13 oz. concentrate milk-based contract formula with iron in stock? If no, how many? ___________

YES NO

2. Are there at least 10 cans of 13 oz. concentrate soy-based contract formula with iron in stock? If no, how many? ___________
3. Are there at least 31 cans of 12.9 oz. powdered milk-based contract formula with iron in stock? If no, how many? ___________
4. Are there at least 20 cans of 12.9 oz. powdered milk -based contract formula with iron in stock? If no, how many? ___________
5. Are all cans of WIC approved formula within current date limit? If no, how many are not? ____________

6. Is the price marked on cans or shelf?
Similac Advance Early Shield with Iron 13 oz. can $________ Powder 12.9 oz. can $__________ Isomil Advance with Iron 13 oz. can $________ Powder 12.9 oz. can $__________

Milk: Minimum 20 gallons skim, low fat (1%), reduced fat (2%) or whole milk of the least expensive brand 1. Is there at least 12 gallons of whole milk in stock? If no, how many? ____________ 2. Are there at least 18 gallons of fat free/skim, low-fat/1% or reduced fat/2% milk in stock? If no, how many? ________ 3. Are there at least 3 boxes of dry powered milk (makes 3 quarts) in stock? If no, how many? ___________

4. Is the price marked on milk, shelf or on the dairy case?

5. Are all containers of WIC approved milk within the date limit? If no, how many were not? _________

Lowest Price

Brand Name/Type

Cheese: Least Expensive Brand Lowest Price

Brand Name/Type

1. Are there at least 8 one-pound packages of cheese in stock? If no, how many? _________

2. Are there at least two kinds of cheese in stock? If no, how many? ___________

3. Is the price marked on cheese or posted on the shelf/dairy case?

4. Are all packages of WIC approved cheese within date limit? If no, how many were not? ___________

YES NO YES NO

Eggs: 1. 2. 3.

Least Expensive Brand Lowest Price

Brand Name/Type

Are there at least 6 dozen grade A large eggs in stock? If no, how many? _________

Is the price marked on eggs or posted on the dairy case?

Are all cartons of WIC approved eggs within date limit? If no, how many were not? ___________

Whole Grain: Highest Price

Brand Name/Type

1. Are there at least 6 loaves of WIC Approved Whole Grain bread? If no, how many? _________________

2. Are they 16 oz. packages? If no, what sizes are in stock? __________________

3. Is the price marked on the bread or posted on the shelf? __

4. Are all the loaves of WIC approved bread within the date limit? If no, how many were not?_______

YES NO YES NO

Fresh Fruits: Highest Price

Brand Name/Type

1. Are there at least 4 types of fresh fruit in stock? If no, how many? _______________________

2. Are there at least 10 pounds of fresh fruit in stock? If no, how many pounds? ________________

3. Is the price marked on or near the fruits or produce bin? ____________

4. Do all fruits appear to be edible?

YES NO

Fresh Vegetables: Highest Price

Brand Name/Type

1. Are there at least 4 types of fresh vegetables in stock? If no, how many? _______________________

2. Are there at least 10 pounds of fresh vegetables in stock? If no, how many pounds? ________________

3. Is the price marked on or near the vegetables or produce bin? _____________

4. Do all vegetables appear to be edible? ___________________

YES NO

YES NO

Fish: Least Expensive Brand Lowest Price

Brand Name/Type

1. Are there at least 18 cans of WIC Approved Fish in stock? If no, how many? ______________

2. Is the price marked on the cans or posted on the shelf? __

3. Are all the cans of WIC approved fish within the date limit? If no, how many were not? ____________

Form 3774 (Rev. 07-09)

DPHP98.8HW

Routing: White Georgia WIC Branch Yellow Vendor

VM-93

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-10

Baby Food: Minimum 96 fruits and vegetables and 93 meats 1. Are there at least 96 4 oz. jars of baby fruits and vegetables in stock? If no, how many? _________

YES

NO

2. Are there at least 31 2.5 oz. jars of baby meats in stock? If no, how many? ___________

3. Are all jars of WIC approved baby food within current date limit? If no, how many are not? _______

4. Is the price marked on the jars or shelf?

Baby Fruit 4 oz. jar

$________

Baby Vegetables 4 oz. jar $________

Baby Meat 2.5 oz. jar

$ ________

NON WIC INVENTORY (Complete during pre-approvals for PG 1 and 2 only. Complete during monitoring for PG 1, 2, 8 only.)

A) Beef, Poultry, Fish, Pork, other Seafood (refrigerated)

YES

1. 0 - 50



2. >50

B) Cereal Products

YES

1. 0 - 50





2. >50

C) Dairy (non-WIC)

YES

1. 0 - 50





2. >50

D) Other Staples (flour, sugar, pasta, puddings, etc.)

YES

1. 0 - 50



2. >50

E) Cans, Jarred and Bottled Foods (meats, vegetables, fruits, condiments, etc.)

YES

1. 0 - 50



2. >50

F) Beverages

YES

1. 0 - 50



2. >50

G) Snack Foods

YES

1. 0 - 50





2. >50

Form 3774 (Rev. 07-09) DPHP98.8HW

VM-94

Routing: White Georgia WIC Branch Yellow Vendor

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-10

General Observations and Questions

N/A

YES NO

1. Were any WIC vouchers on hand in the store? If yes, were the amounts filled in? ____________

2. Did you observe a participant making a purchase? If yes, were appropriate procedures followed? ____________

3. Is there a need for additional training at this time?

4. Is the store open for business 6 days per week 8 hours per day?

5. Does the store have scanners? If yes, can it scan WIC eligible foods? 6. Does the vendor use the WIC acronym of logo in the name or advertisements?

Complete during Monitoring Visit, if applicable: 1. Was this a follow-up visit? If so, what visit is this? ___________ (place the number of this visit here)

The results of this monitoring review have been discussed with me and I have been informed of any violation(s) that were found.

Signature of Vendor Representative

Date

Print Name of Vendor Representative

Title

Comments:

I hereby certify that I have reviewed all WIC approved food items listed on this form. I have discussed all findings and informed the vendor representative of any violation(s). I have provided the vendor representative an opportunity for questions and answers. I have discussed any training needs.

Signature of WIC Representative

Date

Print Name of WIC Representative

Form 3774 (Rev. 07-09) DPHP98.8HW

VM-95

Routing: White Georgia WIC Branch Yellow Vendor

GA WIC 2010 PROCEDURES MANUAL

Attachment VM-11

VM-96

GA WIC 2010 PROCEDURES MANUAL

Food Package

TABLE OF CONTENTS

Page

I. Authorization of Foods ..............................................................................................FP-1

II. Prescribing Foods, General........................................................................................FP-1

A. Contract Versus Non-Contract Formula ...........................................................FP-1

B. Food Package Categories ....................................................................................FP-4

C. Food Packages .......................................................................................................FP-5

D. Required Documentation.....................................................................................FP-7

III. Infants ...........................................................................................................................FP-8

A. Tailoring .................................................................................................................FP-9

B. Feeding Type Assignment .................................................................................FP-11

C. Food Package Assignment.................................................................................FP-11

D. Matching Mother/Baby Food Packages..........................................................FP-13

E. Manual Food Package ........................................................................................FP-14

F. Rounding Infant Age for Manual Food Package Issuance ...........................FP-14

G. Requests for Additional Formula for Mostly Breastfed (MBF) Infants ...................................................................................................................FP-15

H. Physical Form .....................................................................................................FP-16

IV. Women, Children and Infants with Qualifying Medical Conditions ...............FP-16

A. Qualifications for Food Package III Issuance..................................................FP-16

B. Disqualifications for Food Package III Issuance.............................................FP-17

C. Food Packages .....................................................................................................FP-18

D. Tailoring ...............................................................................................................FP-18

E. Food Package Assignment.................................................................................FP-18

F. Manual Food Package ........................................................................................FP-20

G. WIC Foods ...........................................................................................................FP-20

H. Responsibilities ...................................................................................................FP-21

I. Maximum Amounts ............................................................................................FP-21

V. Children Ages 1 to 5 Years ......................................................................................FP-22

A. Tailoring ...............................................................................................................FP-22

B. Food Package Assignment.................................................................................FP-22

GA WIC 2010 PROCEDURES MANUAL

Food Package

C. Manual Food Package ........................................................................................FP-22 D. WIC Foods ...........................................................................................................FP-23 E. Milk Alternatives .................................................................................................FP-24 F. Additional Documentation ...............................................................................FP-25 VI. Women........................................................................................................................FP-25 A. Food Package V ...................................................................................................FP-25 B. Food Package VI..................................................................................................FP-26 C. Food Package VII ................................................................................................FP-26 D. Tailoring ...............................................................................................................FP-27 E. Food Package Assignment.................................................................................FP-27 F. Manual Food Package ........................................................................................FP-28 G. WIC Foods ...........................................................................................................FP-28 H. Milk Alternatives ...............................................................................................FP-29 I. Additional Documentation .................................................................................FP-30 VII. Homelessness, Migrancy, and Disaster Situations ..............................................FP-30 A. Alternative Food Package Assignment............................................................FP-30 B. Food Package Assignment.................................................................................FP-31 C. Manual Food Package .......................................................................................FP-31 D. Assignment of Food Package Code..................................................................FP-31 VIII. Medical Documentation...........................................................................................FP-33 A. Situations Requiring Medical Documentation ..............................................FP-33 B. Acceptable and Unacceptable Forms of Documentation ..............................FP-34 C. Required Medical Documentation Components ..........................................FP-35 D. Verbal Orders .....................................................................................................FP-36 E. Frequency and Records .....................................................................................FP-37 F. Issuance of Ready-to-Feed Products ...............................................................FP-38 G. Medical Diagnoses .............................................................................................FP-39 IX. Formula Distribution/Tracking Guidelines .........................................................FP-41 A. Reasons to Issue Formula ..................................................................................FP-41 B. Maximum Amount to be Issued .......................................................................FP-42 C. Documentation ....................................................................................................FP-42

GA WIC 2010 PROCEDURES MANUAL

Food Package

D. Disposal of Expired Formula ............................................................................FP-42 X. Office of Nutrition Special Formula Orders..........................................................FP-42
A. Ordering ..............................................................................................................FP-42 B. Tracking Log .......................................................................................................FP-43 C. Amount to Order ...............................................................................................FP-43 D. Special Formula Order Form.............................................................................FP-44 E. Frequency ...........................................................................................................FP-44 F. Medical Documentation ....................................................................................FP-44 G. Printing Tracking Voucher ...............................................................................FP-44 H. Flavor ...................................................................................................................FP-44 I. Processing the Order .........................................................................................FP-45 XI. Emory Genetic WIC Clients.....................................................................................FP-45 A. Emory Genetics Prescriptions ...........................................................................FP-46 B. Provision of Formula and WIC Foods..............................................................FP-46 C. Breastfeeding .......................................................................................................FP-47

Attachments:
FP-1 Formula Summary: Standard Formulas for Infants and Children ..................FP-48 FP-2 Contract Formula Food Packages for Fully Formula Fed Infant......................FP-55 FP-3 Food Packages for Exclusively Breastfed Infant .................................................FP-70 FP-4 Food Packages for Mostly Breastfed Infant .........................................................FP-71 FP-5 Non-Contract Formula Food Packages for Fully Formula Fed Infant.............FP-88 FP-6 Contract Formula Food Packages for Children ..................................................FP-98 FP-7 Non-Contract Formula Food Packages for Children .......................................FP-102 FP-8 Summary of Food Packages for Women and Children ..................................FP-104 FP-9 Prenatal/Mostly Breastfeeding Woman ............................................................FP-107 FP-10 Non-Breastfeeding Postpartum /Breastfeeding Some Woman .....................FP-121 FP-11 Exclusively Breastfeeding Single Infant/Prenatal Pregnant
with Multiples........................................................................................................FP-132 FP-12 Exclusively Breastfeeding Multiples ................................................................. FP-147 FP-13 Children 12 23 months.......................................................................................FP-169

GA WIC 2010 PROCEDURES MANUAL

Food Package

FP-14 Children 2 5 years...............................................................................................FP-177 FP-15 Special Formula Summary ...................................................................................FP-188 FP-16 Special Formulas for Infants ................................................................................FP-195 FP-17 Special Formulas for Children.............................................................................FP-223 FP-18 Special Formulas for Women...............................................................................FP-235 FP-19 Tracking Vouchers ................................................................................................FP-240 FP-20 Special Formula Packages for 6 11 Month Old Infants
Who Can't Eat Solids ............................................................................................FP-242 FP-21 Maximum Monthly Amounts Authorized - Fully Formula Fed Infant ........FP-251 FP-22 Maximum Monthly Amounts Authorized - Mostly Breastfed Infant ...........FP-253 FP-23 Maximum Monthly Amounts Authorized - Infant Foods...............................FP-255 FP-24 Supplemental Formula Conversion Table - Modulars ....................................FP-256 FP-25 Maximum Monthly Amounts of Formula Authorized for
Children and Women with Qualifying Conditions .........................................FP-257 FP-26 Maximum Monthly Amounts of WIC Foods Authorized for Children ........FP-258 FP-27 Maximum Monthly Amounts of WIC Foods Authorized for Women .........FP-259 FP-28 Maximum Monthly Amounts for WIC Foods Authorized for
Alternate Food Packages .....................................................................................FP-261 FP-29 How to Convert Breastfeeding Packages...........................................................FP-264 FP-30 Infant Formula Sequencing Exceptions..............................................................FP-267 FP-31 WIC Approved Formulas/Medical Foods .......................................................FP-268 FP-32 Formula Manufacturer's Contact Information .................................................FP-272 FP-33 Special Formula Order Form ...............................................................................FP-273 FP-34 Special Formula Order Tracking Form ..............................................................FP-274 FP-35 Milk/Cheese/Tofu Substitution Tables.............................................................FP-276 FP-36 Instructions for Medical Documentation Form (Form 1) ................................FP-278 FP-37 Medical Documentation Form (Form 1).............................................................FP-286 FP-38 Instructions for Referral Form / Special Food Substitutions (Form 2) .........FP-288 FP-39 Referral Form / Special Food Substitutions (Form 2) .....................................FP-294 FP-40 Georgia WIC Approved Foods List, Criteria to Evaluate an
Eligible Food Item ... ............................................................................................FP-296

GA WIC 2010 PROCEDURES MANUAL

Food Package

FP-41 WIC Approved Foods List October 2009 ...........................................................FP-300 FP-42 Formula Tracking Log ..........................................................................................FP-304 FP-43 Calcium Fortified Juices / Guidelines, Procedures & Recommendations....FP-305 FP-44 List of Single Item or Special Vouchers for 999 Food Packages ....................FP-306

GA WIC 2010 PROCEDURES MANUAL

Food Package

I. AUTHORIZATION OF FOODS
A Competent Professional Authority (CPA)* shall prescribe the categories of authorized supplemental foods in quantities that do not exceed the regulatory maximum and are appropriate for the participant, taking into consideration the participant's age and feeding type. The provision of less than the maximum monthly allowances of supplemental foods to an individual WIC participant is appropriate only when:
1. Medically or nutritionally warranted (e.g., eliminate a food due to an allergy);
2. A participant refuses or cannot use the maximum monthly allowances.
The amounts of supplemental foods shall not exceed the maximum quantities specified in this Section. All participants/caregivers should be instructed on how to select WIC approved foods to receive their maximum allowance.
*A CPA is a nutritionist, registered dietitian, licensed dietitian, registered nurse, licensed practical nurse, physician, or physician assistant.

II. PRESCRIBING FOODS, GENERAL

A. Contract Versus Non-Contract Formula

The State of Georgia has extended the contract with Abbott Laboratories through September 30, 2010 to provide formula for WIC participants. All infants participating in the Georgia WIC Program will be provided with vouchers for a contract formula. The contract infant formulas are Similac Advance EarlyShield Infant Formula (milk-based), Isomil Advance with Iron (soy-based), Similac Sensitive (milk-based lactose free), Similac Sensitive R.S., Similac Go & Grow EarlyShield Milk-Based and Similac Go & Grow Soy-Based. This contract also covers children and women who require a contract infant formula as a source of nutrition. The contract currently provides the following rebate on each container of Similac Advance EarlyShield, Isomil Advance, Similac Go & Grow EarlyShield Milk-Based, Similac Go & Grow Soy-Based, Similac Sensitive, and Similac Sensitive R.S. purchased. (Numbers are rounded to the nearest whole cent.)

Similac Advance EarlyShield Concentrate (13 ounces): Powder (12.9 ounces):

$3.49 $10.07

FP-1

GA WIC 2010 PROCEDURES MANUAL

Food Package

Ready-To-Feed (per 6-pack of 8 oz.): Ready-To-Feed (32 ounces):

$3.16 $2.24

Isomil Advance Concentrate (13 ounces): Powder (12.9 ounces): Ready-To-Feed (per 6-pack of 8 oz.): Ready-To-Feed (32 ounces):

$3.84 $10.86 $3.16 $2.14

Similac Go & Grow EarlyShield Milk-Based Powder (12.9 ounces): Powder (22 ounces):

$7.64 $14.08

Similac Go & Grow Soy-Based Powder (12.9 ounces): Powder (22 ounces):

$7.47 $14.68

Similac Sensitive Concentrate (13 ounces): Powder (12.9 ounces): Ready-To-Feed (32 ounces):

$3.84 $10.86 $2.14

Similac Sensitive R.S. Ready-To-Feed (32 ounces): Powder (12.9 ounces):

$ 1.95 $10.63

When the Abbott Laboratories wholesale formula prices increase, the amount of Georgia's rebate increases cent for cent beginning the month in which the increase goes into effect.

Contract formulas not requiring a prescription: Similac Advance EarlyShield Isomil Advance

1. Milk-Based Formula:
All participants who receive a milk-based infant formula will receive the contract formula Similac Advance EarlyShield.

The Georgia WIC Program does NOT APPROVE the following non-contract milk-based infant formulas for distribution. Therefore, prescriptions will not be accepted for: Nestl Good Start Gentle PLUS
Nestl Good Start Gentle PLUS 2

FP-2

GA WIC 2010 PROCEDURES MANUAL

Food Package

Nestle Good Start Nourish PLUS Nestl Good Start Protect PLUS Nestl Good Start Protect PLUS 2 Nestl NAN & Nestl NAN DHA & ARA Enfamil LIPIL Enfamil Gentlease LIPIL Enfagrow PREMIUM Enfamil Premium Enfamil RestFull Parent's Choice (milk-based) Store brand milk-based infant formulas Organic Formula (Any Type)
2. Soy-Based Formula: All participants who receive a soy-based infant formula will receive the contract formula Similac Isomil Advance. The contract soy formula should be tried before progressing to non-contract soy infant formulas.
The following non-contract soy based formulas ARE APPROVED for distribution by the Georgia WIC Program with valid medical documentation of a qualifying medical condition: Nestl Good Start Soy PLUS Nestl Good Start Soy PLUS 2 Enfamil ProSobee LIPIL Enfamil Soy LIPIL Enfagrow Soy Parent's Choice Soy Store brand soy-based formulas that are USDA approved
3. Lactose Free Formula: All participants who receive a milk-based, lactose free infant formula will receive the contract formula Similac Sensitive or Similac Sensitive R.S. Both Similac Sensitive and Similac Sensitive R.S. can only be distributed by the Georgia WIC Program with valid medical documentation of qualifying medical conditions.
The Georgia WIC Program does NOT APPROVE Enfamil

FP-3

GA WIC 2010 PROCEDURES MANUAL

Food Package

Gentlease LIPIL for distribution. Prescriptions will not be accepted for Enfamil Gentlease LIPIL for any reason.
4. Formula Changes
Whenever medical condition(s)/diagnosis(es) warrant a change from the contract formula, the WIC Program may provide the infant another approved formula upon receipt of proper medical documentation. Vouchers will specify the prescribed formula. Refer to Section VIII (Medical Documentation) for information regarding the required medical documentation for qualifying medical conditions.

B. Food Package Categories
There are seven (7) food package categories authorized by Federal WIC Regulations. Each group is specified according to age, condition, and/or formula type (in the case of Food Package III). The groups are:

Food Package Name from the Federal WIC
Regulations

Age/Condition

Food Package IA

Fully Formula Fed (FFF) infants ages 0 through 3 months

Food Package Series Number
(Internal)
A00-A99

Mostly Breastfed (MBF) infants ages 0 through 1 month

E02 E60, E70 E99

Mostly Breastfed (MBF) infants ages 1 through 3 months

E02 E60, E70 E99 F00 F99, J00 J99, K00 K99

Exclusively Breastfed (EBF) infants

ages 0 through 5 months

E00

Food Package IB

Fully Formula Fed (FFF) infants ages 4 through 5 months

(B00 B99)

Mostly Breastfed (MBF) infants ages 4 through 5 months

(G00 G99) E00 E99, J00 J99, K00 K99

FP-4

GA WIC 2010 PROCEDURES MANUAL

Food Package

Food Package Name from the Federal WIC
Regulations

Age/Condition

Food Package II

Fully Formula Fed (FFF) infants ages 6 through 11 months

Food Package Series Number
(Internal)
(D00 D99)

Mostly Breastfed (MBF) infants ages 6 through 11 months

(H00 H99), (L00 L99), (M00 M99), (N00 N99)

Food Package III Food Package IV

Exclusively Breastfed (EBF) infants

ages 6 through 11 months

(E01)

Medically fragile women, infants, and children with qualifying medical conditions receiving special formulas/medical foods

R00 R99, (S00 S99), (T00 T99)
X00 X99

Children ages 1 to 5 years

C00 C99

Food Package V

Pregnant women Mostly breastfeeding women

W01 W19

Food Package VI

Non-breastfeeding women Women breastfeeding some

W20 W39

Food Package VII

Exclusively breastfeeding women
Women pregnant with multiple fetuses
Women mostly breastfeeding multiples

W40 W79 (V60 V79)

C. Food Packages
Food Packages are foods from the Georgia WIC Approved Foods List in combinations and amounts to meet USDA Federal Regulations for WIC participants by WIC type.
Food packages translate the foods authorized in each food package category group into allowed amounts of Georgia approved foods. Food packages include standard food packages and packages to meet special nutritional needs (e.g., lactose intolerance). See Attachments FP-1 to FP-20.
All formulas, medical foods and supplemental foods that are authorized

FP-5

GA WIC 2010 PROCEDURES MANUAL

Food Package

for distribution through the WIC Program must first be determined WICeligible by the Food and Nutrition Service, United States Department of Agriculture. The Office of Nutrition may then approve distribution of the product through the Georgia WIC Program.
1. Tailoring: Available computer food packages contain the maximum amounts of allowed foods. This is called the "full nutritional benefit." Any food grouping that includes maximum amounts of allowed foods may be prescribed. See Attachments FP-1 to FP-20 for a list of numbered food packages.
No matter how many family members are participating in the WIC Program, each participant's nutritional needs must be given individual consideration.
Participants or their caretaker should be advised that the supplemental foods issued are only for their personal use. However, the supplemental foods are not authorized for participant use while hospitalized on an in-patient basis. In addition, supplemental foods are not authorized for use in the preparation of meals served in a communal food service. This restriction does not preclude the provision or use of supplemental foods for individual participants in a nonresidential setting (e.g., child care facility, family day care home, school, or other educational program); a homeless facility or a residential institution (e.g., home for pregnant teens, prison, or residential drug treatment center) that allows for individuals to store their WIC foods for their personal use apart from community prepared foods.
2. Assignment of CPA Food Package Code (CPA FPC): CPA FPC is the "umbrella" code assigned to a WIC participant that reflects the foods and quantities of foods to be issued over a certification period. Each CPA FPC may be subcategorized into multiple internal food package codes based on the participant's age at voucher issuance and in the case of infants feeding type. The CPA assigns the CPA FPC that coincides with the types of foods desired based on the participant's category. If a state-created food package that meets the needs of the participant is not available, the CPA specifies the quantities/items desired and assigns a District/clinic-created 999 food package (food package in the 900999 number series). A 999 food package may include any allowed

FP-6

GA WIC 2010 PROCEDURES MANUAL

Food Package

food combination, up to the maximum allowed. Allowable foods and maximum quantities will vary depending on participant category. Refer to Attachments FP-21 to FP-28 for maximum monthly amounts authorized. See Attachment FP-44 for voucher codes for single food items and small quantity vouchers.
3. Assignment Method: The CPA must evaluate and assign food packages: a. At each WIC assessment/certification
b. Upon receipt of medical documentation prescribing a new food/foods
c. At the request of the participant
Only WIC CPA staff are authorized to assign food packages.

D. Required Documentation
1. General Documentation:
a. During the WIC assessment/certification, the CPA must enter the CPA Food Package Code in the "Food Package" space provided on the WIC Assessment/ Certification Form or directly into the applicable field in the front-end computer system. Specific foods or voucher codes to be issued for food package 999 must be documented on the WIC Assessment/Certification Form or in the progress notes of the participant's health record.
b. Food package changes occurring between WIC certifications must be documented on the WIC Assessment/Certification Form. The date of the food package change and the CPA's signature and title must be included in the documentation. The use of a signature stamp is not acceptable. Secondary nutrition education provided with food package changes must be documented in the medical record.
2. Additional Documentation:
Medical documentation is required for the following situations:

FP-7

GA WIC 2010 PROCEDURES MANUAL

Food Package

a. Contract formulas requiring a prescription (Similac Sensitive, Similac Sensitive R.S., Similac Go & Grow EarlyShield Milk-Based, Similac Go & Grow Soy-Based).
b. Non-contract infant formulas for infants, any infant formulas for children or women, any exempt infant formulas, and any medical foods (e.g., as indicated for chronic diseases or medical conditions).
c. Women and children who require more than one pound of cheese per month or women receiving Food Package VII who require more than three pounds of cheese per month.
d. Children who require any amount of tofu or soy milk.
e. Women who require more than four pounds of tofu or women receiving Food Package VII who require more than six pounds of tofu.
3. CPA documentation is required for: a. Issuance of ready-to-feed formulas, unless ready-to-feed is the only available form of the product.
b. Disaster situations.
c. Issuing less than the maximum monthly allowance of supplemental foods (e.g., to omit a food due to a food allergy).

III. INFANTS
Food Package I is for infants 0 through 5 months of age and consists only of ironfortified infant formula. Food Package II is for infants 6 through 11 months of age and consists of iron-fortified infant formula, iron-fortified infant cereal, and infant fruits and vegetables. Infant cereal and infant fruits and vegetables may not be assigned to an infant less than 6 months old. Exclusively breastfed infants 6 through 11 months of age also receive infant meats. Food Packages I and II are designed for issuance to infants who do not have a medical condition qualifying them to receive Food Package III. Infant formula is the only category of formula authorized in this food package. Exempt infant formulas and WIC-eligible medical foods are authorized only in Food Package III.
FP-8

GA WIC 2010 PROCEDURES MANUAL

Food Package

Cow's milk and goat's milk are not authorized for infants in the first 12 months of life.
Infant Formula: defined by USDA as a nutritionally complete, iron-fortified standard or slightly modified formula for use in full-term infants. Infant formulas provide 20 calories per fluid ounce at standard reconstitution. Examples include Similac Advance EarlyShield, Isomil Advance, Similac Sensitive, Similac Sensitive R.S., Enfamil AR LIPIL, ProSobee LIPIL, Enfamil Soy LIPIL, Nestl Good Start Soy PLUS, Similac Go & Grow EarlyShield Milk-Based, and Similac Go & Grow Soy-Based.
Exempt Infant Formula: defined by USDA as infant formula designed for infants with medical conditions (e.g., prematurity, low birth weight, metabolic disorders, etc.). Some exempt infant formulas are also classified as medical foods. Examples of exempt infant formulas include EleCare, Nutramigen LIPIL, premature infant formulas (such as Similac NeoSure or Similac Special Care), Cyclinex-1, Alimentum, Isomil DF, Pregestimil LIPIL, and Neocate Infant.
Medical Foods: A WIC-eligible medical food refers to certain enteral products that are specifically formulated to provide nutritional support for individuals with a diagnosed medical condition when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible medical foods may be nutritionally complete or incomplete, but they must serve the purpose of a food, provide a source of calories and one or more nutrients, and be designed for enteral digestion via an oral or tube feeding. WIC-eligible medical foods include many, but not all, products that meet the definition of medical foods. Examples of medical foods include PediaSure, Nutren 2.0, Boost, Peptamen Jr., Polycose, Cyclinex-1, Neocate One+, and human milk fortifier.
To determine if a product is an infant formula, an exempt infant formula, or a medical food, visit the WIC Works Formula Database at the following website: http://grande.nal.usda.gov/wicworks/formulas/FormulaSearch.php .
A. Tailoring
1. Breastfed Infants: The best food for most infants is breast milk. Since the maternal milk supply is not well established until 4-6 weeks of lactation, it is best if no formula is offered to infants during this time. If the CPA deems it appropriate, one can of powder formula may be issued during the first month of life.
If a mother chooses to both breastfeed and formula feed her infant, powder formula is recommended. However, liquid

FP-9

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concentrate formula is available. The CPA should assign a food package with only the amount of formula the infant requires (one can, two cans, or three cans powder). The CPA should reassess the infant's needs any time the mother requests more formula. Any problems with breastfeeding should be addressed at this time. Requests for increases in the amount of formula should not be honored without assessment and counseling of the mother/baby dyad.
2. Formula Fed Infants: When the participant is not breastfed, a contract infant formula should be prescribed unless appropriate medical documentation is provided. The amount of formula provided varies with age and feeding type.
The issuance of any contract brand or non-contract brand infant formula that contains less than 10 milligrams of iron per liter at standard dilution (i.e., approximately 20 kilocalories per fluid ounce of prepared formula) is prohibited.
3. Cereal: Cereal is not authorized for the infant 0 through 5 months of age. Infants 6 11 months old will receive the full nutritional benefit of twenty-four (24) ounces of infant cereal per month.
4. Infant Fruits and Vegetables: Infant fruits and vegetables are jars of baby food containing single-ingredient fruits (e.g., baby food peaches) or single-ingredient vegetables (e.g., baby food peas). Infant fruits and vegetables are not authorized for the infant 0 through 5 months of age. The full nutritional benefit for Fully Formula Fed (FFF) and Mostly Breastfed (MBF) infants is 128 ounces (32 4 oz jars) of infant fruits and/or vegetables. Exclusively Breastfed (EBF) infants receive 256 ounces (64 4 oz jars) of infant fruits and/or vegetables. Georgia WIC authorizes only Stage 2 (2nd Foods) single- ingredient infant fruits and vegetables.
5. Infant Meats: Infant Meats are jars of baby food containing singleingredient meats (e.g., baby food beef and beef broth or chicken and chicken gravy). Infant meat is not authorized for the infant 0 through 5 months of age. The full nutritional benefit is 77.5 ounces (31 2.5 oz jars) of infant meat. No meat mixtures are

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allowed. Infant meat is only authorized for Exclusively Breastfed (EBF) infants 6 through 11 months of age.

B. Feeding Type Assignment
Three infant feeding options are available Exclusively Breastfed (EBF), Mostly Breastfed (MBF), or Fully Formula Fed (FFF).
1. Exclusively Breastfed (EBF) infants receive no formula from the WIC Program.
2. Mostly Breastfed (MBF) infants receive formula in amounts that do not exceed the maximum allowed for mostly breastfed infants in the federal regulations (approximately half [50%] of the full formula package issued to FFF infants).
3. Fully Formula Fed (FFF) infants receive formula in excess of the amount allowed for mostly breastfed infants in the federal regulations. This applies even if they are receiving some breast milk.

C. Food Package Assignment
1. For Fully Formula Fed (FFF) infants each CPA Food Package Code (CPA FPC) represents three or more packages one for each infant age group (0 through 3 months, 4 through 5 months, and 6 through 11 months.) A different amount of formula is allowed for each age group. Infants age 4 through 5 months receive slightly more formula than do infants age 0 through 3 months. Infants age 6 through 11 months receive less formula but with the addition of baby cereal and baby food (infant fruits and vegetables).
Georgia WIC computer systems are automated to progress the infant through these three age groups. The CPA FPCs for FFF infant packages start with an "A." The computer will issue food packages beginning with an "A" to FFF infants ages 0 through 3 months old, a "B" package to FFF infants ages 4 through 5 months old, and a "D" package to FFF infants ages 6 through 11 months old.

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2. Mostly Breastfed (MBF) infants are infants who receive formula from the WIC Program in amounts that do not exceed the maximum allowed for mostly breastfed infants (approximately half [50%] of the full formula package issued to FFF infants).

a. Food Packages

Food packages containing the maximum formula allowed for a MBF infant begin with an "F." The computer will issue food packages beginning with an "F" to MBF infants ages 1 month through 3 months old, a "G" package to MBF infants ages 4 through 5 months old, and an "H" package to MBF infants ages 6 through 11 months old for the Mostly Breastfed maximum formula food package. Food packages for MBF infants needing only 1 can, 2 cans or 3 cans of powder formula per month begin with "E," "K," and "J," respectively. The WIC computer system will automatically add the cereal and baby food to the food packages when the infant is 6 months old.

Food Package Code Begins With:
F G H E K J L M N

Infant Age
1-3 months 4-5 months 6-11 months 0-5 months 1-5 months 1-5 months 6-11 months 6-11 months 6-11 months

Formula Amount
Maximum MBF Maximum MBF Maximum MBF 1 can powder 2 cans powder 3 cans powder
1 can powder 2 cans powder 3 cans powder

b. First Month
During the first month of life, the Mostly Breastfed (MBF) infant may not receive more than 104 reconstituted fluid ounces of formula from WIC (approximately 1 can of powder formula). Infant formula issuance is limited during this time period to support the successful establishment of breastfeeding.

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When an infant's initial certification is during the first month of life, the CPA will assign the CPA FPC that provides the amount of formula that should be issued after the first month. After entering the CPA FPC in the computer system, a second box will appear for the CPA to enter the FPC for the first month. From 0 to 20 days of age this can either be E00 (no formula) or the appropriate FPC for 1 can of powder formula (i.e., E11 for Similac Advance EarlyShield).
From 21 days to 1 month the CPA is allowed a third choice for the first month's food package. Since the infant is almost 1 month old, the CPA can assign the same package as the CPA FPC or the full amount of formula being prescribed after the first month. For example, F11 would provide the maximum formula (4 cans) allowed for 1- 3 month old.
3. Exclusively Breastfed (EBF) infants receive no formula from the WIC Program. At 6 months of age, EBF infants receive infant cereal, infant fruits and vegetables, and infant meats. EBF infant food package codes are E00 and E01. The computer will automatically advance the food package at age 6 months from E00 to E01.

D. Matching Mother/Baby Food Packages
"Mother/baby dyad" refers to the process of thinking of a mother and her infant as a unit or pair rather than as two individuals. The mother/baby dyad food packages must agree. For instance, the mother of an infant assigned a food package for an Exclusively Breastfed (EBF) infant must be issued a package for an Exclusively Breastfeeding (EBF) woman. The table below matches the appropriate mother's food package to her infant's food package. The infant's food package should be assigned first since the mother's food package is based on the amount of formula her infant receives from WIC.

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If Infant Receives: Exclusively Breastfed (EBF) food package (receives no formula from WIC) Mostly Breastfed (MBF) food package (does not exceed monthly formula allowance for Mostly Breastfed infant) Formula in an amount that exceeds the monthly allowance for a Mostly Breastfed infant (e.g., a Fully Formula Fed [FFF] food package) and breast milk
Fully Formula Fed (FFF) food package and no breast milk

Then Mother Receives: Exclusively Breastfeeding (EBF) woman food package
Mostly Breastfeeding (MBF) woman food package
If less than 6 months postpartum: a Some Breastfeeding (SBF) woman food package
If greater than 6 months postpartum: Some Breastfeeding (S) woman food package W80 (with no foods) If less than 6 months postpartum: Non-Breastfeeding woman food package

If greater than 6 months postpartum: mother is no longer WIC eligible

E. Manual Food Package

When Voucher Printing on Demand (VPOD) is not available, a manual food package for age or equivalent (i.e., concentrate or powder) should be issued to infants. Manual vouchers will be available for Similac Advance EarlyShield for food packages A11, B11, and D11. If a manual food package is not available for the type and/or the amount of formula the infant receives, the food package should be issued on a blank voucher(s). When using blank vouchers for state-created food packages, the ageappropriate internal food package codes should be listed on the blank voucher rather than the CPA FPC. For example, a 4-month-old infant on Similac Sensitive would be issued FPC B31 not the CPA FPC A31.

F. Rounding Infant Age for Manual Food Package Issuance

"First Day to Use" date is the date the WIC participant is first allowed to cash their WIC voucher. When calculating infant's age to determine which food package to issue when using manual or blank vouchers, round as follows:

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x If the infant's age on the "First Day to Use" date for the voucher is 0 to 15 days old, round down to nearest month.
x If the infant's age on the "First Day to Use" date for the voucher is 16 30 days old, round up to nearest month.
The WIC computer system will normally make this age determination. The WIC staff will only have to calculate age when the WIC computer system is unavailable.
G. Requests for Additional Formula for Mostly Breastfed (MBF) Infants

To promote breastfeeding, the infant should be issued the smallest amount of formula needed. Additional formula can be issued as long as the infant does not exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants.
If the infant's needs exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants and the mother has used some of her vouchers for that month use the instructions in Attachment FP-29 to calculate whether a food package change can be made for the current month. The standard MBF food package W01 cannot be changed to food package W21 during the same month if voucher code W02 or both voucher codes 041 and 040 have already been spent by the mother. The women can be issued any foods allowed in the new food package that she has not already received by cashing a voucher from her old food package. State-created vouchers have been designed for use in converting the standard Mostly Breastfeeding package (W01) to the standard Some Breastfeeding or NonBreastfeeding package (W21). See Attachment FP-29 on how to use voucher codes A34 and W71 to make this transition. If the infant's needs exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants and the mother has used vouchers for that month which would result in her food package not being able to be converted to the new food package, then the food package change for both the infant and mother would be effective the following month.
If the mother has not used any of her vouchers for that month, then the clinic may void the current vouchers for the mother and re-issued the new food package. When reissuing the infant's vouchers take into consideration which, if any, of the infant vouchers have already been cashed. Subtract any formula already issued from the amount being reissued.

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H. Physical Form
Local agencies must issue all WIC formulas (infant formula, exempt infant formula and WIC-eligible medical foods) in concentrated liquid or powder physical forms. Ready-to-feed WIC formulas may be authorized when the CPA determines and documents that:
(1) The participant's household has an unsanitary or restricted water supply or poor refrigeration;
(2) The person caring for the participant may have difficulty in correctly diluting concentrated or powder forms; or
(3) The formula is only available in a ready-to-feed form.
In addition, participants with qualifying medical conditions who are assigned to Food Package III can also be issued ready-to-feed formulas for the additional reasons below:
(4) If the ready-to-feed form better accommodates the participant's medical condition (Food Package III clients only); or
(5) If the ready-to-feed form improves the participant's compliance in consuming the prescribed formula (Food Package III clients only).

IV. WOMEN, CHILDREN AND INFANTS WITH QUALIFYING MEDICAL CONDITIONS
Food Package III is reserved for issuance to women, infants and children who have a documented qualifying medical condition(s) that requires the use of a WIC formula (infant formula [children & women only], exempt infant formula or WIC-eligible medical food) because the use of conventional foods is precluded, restricted, or inadequate to address their special nutritional needs. Medical documentation must meet the requirements described in Section VI of the Food Package (FP) Section.
A. Qualifications for Food Package III Issuance
1. Food Package III requires two components:

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a. Diagnosis of a qualifying medical condition and
b. A prescription
(1) For an infant receiving an exempt infant formula or medical food, or
(2) For a women or child receiving a medical food, infant formula, or an exempt infant formula
2. Qualifying medical conditions must be diagnosed by a health care professional licensed to write medical prescriptions in the State of Georgia. Qualifying medical conditions include, but are not limited to, premature birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, malabsorption syndromes, immune system disorders, severe food allergies that require an elemental formula, and life threatening disorders, diseases and medical conditions that impair ingestion, digestion, absorption or the utilization of nutrients that could adversely affect the participant's nutrition status. Food Package III may not be issued solely for the purpose of enhancing nutrient intake or managing body weight (e.g., to treat "weight loss" or "poor weight gain").

B. Disqualifications for Food Package III Issuance
1. Food Package III is not authorized for infants whose only condition is: a. A diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein or soy protein that does not require the use of an exempt infant formula; or b. A non-specific formula or food intolerance.
2. Other participants who do not qualify for Food Package III include: a. Infants receiving non-contract standard infant formulas. b. Infants receiving standard infant formula via tube-feeding due to a medical condition. c. Infants receiving a standard infant formula requiring a prescription (e.g., Similac Sensitive R.S.).

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d. Children or women diagnosed with a medical condition that does not require the use of a formula or medical food.
C. Food Packages
1. Infant food packages in Food Package III only consist of exempt infant formula or medical food(s) plus infant cereal and infant fruits and vegetables as allowed for age, if appropriate for the medical condition. Infant meats are not authorized for issuance in Food Package III since Exclusively Breastfed (EBF) infants by definition do not receive any formula from WIC and therefore could not be receiving exempt infant formula or medical food(s) as required for Food Package III.
2. Child and woman food packages in Food Package III may consist of infant formula, exempt infant formula, and/or medical food(s) and any of the foods in the standard children or women packages (cereal, juice, milk, cheese, whole grain bread or alternatives, beans, peanut butter, eggs, and fruits and vegetables).

D. Tailoring
Due to the varying ages and medical conditions, tailoring for this package must be carefully individualized. The Georgia WIC Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) allows the health care provider to list the name of the special formula prescribed and indicate which authorized supplemental foods, if any, are not allowed due to the participant's medical condition. Please refer to section VIII of this Food Package (FP) Section of the manual for medical documentation procedures.
E. Food Package Assignment
1. Infant
Each infant CPA Food Package Code (FPC) represents three packages one for each infant age group (0 through 3 months, 4 through 5 months, and 6 through 11 months). A different amount of formula is allowed for each age group. Infants 4 through 5 months of age receive slightly more formula than the 0 through 3 month old infant. Infants 6 through 11 months of age receive less formula, but with the addition of baby cereal and baby food

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fruits and vegetables. Infant CPA FPCs for exempt infant formulas begin with a "R." The computer will automatically sequence the infant through the "S" (4 through 5 months) and "T" packages (6 through 11 months).
Infants ages 6-11 months old who are unable to consume solid foods due to their qualifying medical condition(s) and who are assigned to Food Package III are eligible to receive formula at the higher maximum allowance rate allowed for infants ages 4-5 months old (based on their feeding method). If the infant age 611 months old is unable to eat solid foods, the CPA can assign a CPA FPC code beginning with an "S" so that the infant can receive additional formula in place of the supplemental foods. Although used differently the internal "S" food package is identical to the CPA FPC "S" package.
Exceptions there are a few powder exempt infant formulas that do not follow the standard sequencing described in the preceding paragraphs. The state-created food packages for powder Alimentum, Nutramigen AA LIPIL, and Pregestimil LIPIL have special sequencing patterns to avoid over or under issuance. See Attachment FP-30 to view the sequencing patterns for these formulas.
2. Women and Children
The food package codes for special formulas for women and children begin with an "X." When the CPA assigns a special formula package beginning with an "X," a second food package field will be enabled in the computer system to allow the CPA to enter a food package for the appropriate supplemental foods based on the medical documentation provided. The food package could be a child or woman's state-created food package or a 999 food package if none of the standard state-created food packages meet the medical food prescription. The special formula food package (food package beginning with an "X") must be entered into the computer as the first food package code to enable the second field.
If the WIC participant only needs the "X" package, enter "000" in the second food package field to indicate that supplemental foods do not need to be issued.

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If none of the state-created formula food packages meet the prescription needs of the participant, a 999 food package can be assigned in the first box to allow the CPA to design an individualized package.
F. Manual Food Package
There is no standard manual food package for Food Package III. Each package is tailored to meet the participant's needs. If manual vouchers are needed, use blank vouchers.
G. WIC Foods
1. Children may receive any infant formula, pediatric formula or medical food on the Georgia WIC Program approved formula list. Women may receive any adult formula or medical food on the Georgia WIC Program approved formula list. See Attachment FP-31 or visit the Georgia WIC website at http://health.state.ga.us/programs/wic/wicformula.asp.
2. The maximum amount of formula or medical food allowed is based on reconstituted fluid ounces of the product. To determine the maximum number of containers allowed see Attachments FP21, FP-22, and FP-25. If the product does not have standard mixing instructions (e.g., many metabolic formulas), then the formula should be issued by weight. See Attachments FP-21, FP22, and FP-25. If the prescribed product reconstitutes to an amount not listed or if the container size (if calculating by weight) is not on the tables, then call the Office of Nutrition for assistance.
Women and children may receive up to the maximum quantities allowed for their WIC category of the juice, milk, cereal, eggs, fruits and vegetables, whole wheat bread or alternative, peanut butter and beans/peas as prescribed by their health provider on the Medical Documentation Form (Form #1). No supplemental foods may be issued to a Food Package III participant without appropriate medical documentation. See maximum food quantities for children on Attachment FP-26 and women on Attachment FP-27.

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If the prescribing authority requests whole milk on the medical documentation form for a food package III participant whole milk may be issued to women and children over age 2.

H. Responsibilities
Due to the nature of the health conditions of participants who are issued supplemental foods that require medical documentation, close medical supervision is essential for each participant's nutritional management. Per federal regulations, this responsibility remains with the participant's health care provider for this medical oversight and instruction. This responsibility cannot be assumed by personnel at the WIC State or Local Agency. However, it is the responsibility of the Local WIC Agency to ensure that only the amounts of supplemental foods prescribed by the participant's health care provider are issued in the participant's food package. CPAs should provide high risk counseling according to WIC procedures.
Medical documentation and/or prescriptions signed by dietitians cannot be accepted. Dietitians do not have prescriptive authority as outlined in the laws of the State of Georgia. However, a Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) may: a. Recommend to a physician, certified nurse practitioner, or
physician assistant a suitable alternative formula, or b. Refer a participant to a physician, certified nurse practitioner, or
physician assistant for evaluation.

I. Maximum Amounts
See Attachment FP-25 for maximum amounts of formula authorized for women and children. The maximum amounts of formula, cereal, and infant food fruits and vegetables authorized for infants is the same as infants in Food Packages I and II. See Attachments FP-21 to FP-23. The maximum amount of supplemental foods for women and children is the same as the amounts they would have received had they not qualified for Food Package III. See Attachments FP-26 to FP-27.

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V. CHILDREN AGES 1 TO 5 YEARS
Food Package IV is for children 1 to 5 years of age. This food group consists of milk, cheese, cereal, juice, eggs, whole grain bread or alternative, fruits and/or vegetables, and beans/peas or peanut butter.
A. Tailoring
It is federally mandated that a food package be prescribed that provides the maximum monthly allowance of supplemental foods. This applies even when there are two (2) or more family members participating on the WIC Program.
The CPA can assign a standard package or a package with an alternative dairy option such as lactose reduced milk or goat's milk.
B. Food Package Assignment
The food packages for children ages 1 to 5 years are listed in Attachments FP-13 and FP-14. Food package codes for children ages 12-23 months are C01 C11 and ages 2-5 years old are C21 C31. Refer to Attachments FP26 for the maximum amounts of each food item allowed per month.
Children ages 24 months and older in Food Package IV are required by federal regulations to be issued only low-fat milk. Younger children (ages 12-23 months old) are only authorized to receive whole milk from the WIC Program. The computer system will automatically transition a child from the whole milk food package to the low-fat milk food package on the first set of vouchers printed with a "First Day to Use" date on or after the child is age 23 months 16 days old.
C. Manual Food Package
When Voucher Printing on Demand (VPOD) is not available, a manual food package should be issued. If a manual food package is not available for the food package the child receives, then the food package should be issued using blank vouchers.
Manual vouchers are available for the standard food packages for children: C01 for children ages 12-23 months and C21 for children 2-5 years old.

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D. WIC Foods
1. Juice: Children will be issued single strength juice in 64 oz bottles.
2. Milk: Children greater than 23 months 15 days of age will have a choice between two standard food packages C21 (with 1 pound of cheese substituted for part of the milk) or C28 (with all milk and no cheese). Food package C21 does include one box of dry powder milk in order to provide the full nutritional benefit mandated by federal regulation. If the participant does not want the dry powder milk, the clinic has two options: a. Issue food package C28 with no cheese instead, or b. Create a 999 food package using state-created vouchers, and replace the voucher containing dry powder milk (voucher code C02) with one containing an equivalent quantity of evaporated milk (voucher code C25).
Children 12-23 months of age will receive whole milk and no cheese. Federal regulations prohibit issuance of low-fat milk by the WIC Program to children ages 12-23 months old. Therefore, prescriptions for low-fat milk cannot be accepted for any reason for children in this age group. Children ages 12-23 months old with a medically indicated need to reduce their fat or caloric intake should be instead provided appropriate nutritional counseling according to standard high risk education procedures.
Children ages 24 months and older will receive low-fat milk. Prescriptions for whole milk cannot be accepted for any reason for children ages 24 months old receiving Food Package IV. (Note: Only children ages 24 months old receiving a formula or medical food due to a qualifying medical condition [in Food Package III] can be issued whole milk if the medical documentation provided allows milk issuance.)
3. Cheese: The standard food package for children 12 - 23 months old does not include cheese. However, a 999 food package containing cheese can be created for children in this age range who have medical documentation of a qualifying condition (e.g., lactose intolerance).

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For children 2-5 years of age, the CPA may assign a food package with or without cheese substituted for a portion of the milk allowance. The food package containing cheese has some of the milk given in the dry powder form.
Additional cheese may be issued in place of milk to children with medical documentation. When "extra cheese" is prescribed, any remaining milk allotment must be issued in full. This may require the issuance of either dry powder milk or evaporated milk for a portion of the milk allowance. See Attachment FP-35 for a chart listing the amount of fluid and dry powder milk to be issued based on the amount of cheese prescribed. Issuing greater than one (1) pound of cheese per month to a child requires medical documentation.
4. Fruits and Vegetables: The fruit and vegetable voucher cannot be counted when prorating vouchers. If a participant is eligible to receive any voucher for the month, the participant must be issued the fruit and vegetable voucher.
5. Peanut Butter: The food packages for children ages 12 - 23 months old do not contain peanut butter because of the risk of choking.
6. Other WIC Foods: For information on package sizes and restrictions see the Georgia Approved Food List (Attachment FP41).

E. Milk Alternatives
For children, cheese, calcium-set tofu, or soy milk may be substituted for milk as described below. The issuance of any soy milk, any tofu, or extra cheese (>1 pound per month) to children requires medical documentation to ensure that the medical provider is aware that the child is receiving a cow's milk substitution. Medical documentation can include religious and cultural reasons (e.g.., vegan or vegetarian) as acceptable reasons to issue soy milk and tofu.
Cheese: Cheese may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk. A maximum of 1 pound of cheese can be substituted in this manner without requiring medical documentation. With medical documentation of a qualifying medical condition such as

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lactose intolerance, additional amounts of cheese may be substituted up to the maximum of four (4) pounds of cheese.
Soy Milk: Soy milk may be substituted for cow's milk at the rate of 1 quart of soy milk for 1 quart of milk, up to the total maximum monthly allowance of milk (16 quarts). Children must have medical documentation of a qualifying medical condition to receive any amount of soy milk.
Tofu: Calcium-set tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk, up to a maximum of 8 pounds of tofu per month. Children must have medical documentation for a qualifying medical condition to receive any amount of tofu.
F. Additional Documentation

CPAs must thoroughly document any situation in which less than the full maximum allotment of a supplemental food is issued to a participant (e.g., at the participant's request, due to a food allergy, etc.).
Medical documentation is required in the following situations:
1. Any authorized soy milk or tofu issued to children.
2. Any authorized cheese issued to children that exceeds the maximum substitution rate of one (1) pound per month.

VI. WOMEN
Women participating on the WIC Program and who do not have a medical condition qualifying them for Food Package III are categorized into three federal Food Packages: V, VI, and VII. Each federal Food Package consists of different quantities of supplemental foods, different allowed supplement foods, and/or different eligibility periods and requirements.
A. Food Package V is for two categories of women:
1. Women with a singleton pregnancy ("Prenatal")
2. Women who are mostly breastfeeding up to one year postpartum ("Mostly Breastfeeding Women") and whose Mostly Breastfed (MBF) infants receive formula from the Georgia WIC Program in
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amounts that do not exceed the maximum allowances for Mostly Breastfed infants.
Food Package V consists of milk, cheese, cereal, juice, eggs, whole grain bread or alternative, fruits and/or vegetables, beans/peas or peanut butter.
B. Food Package VI is for two categories of women:
(1) Women up to six months postpartum who are not breastfeeding their infants ("Non-Breastfeeding/Fully Formula Feeding Women"). At six months postpartum, the non-breastfeeding postpartum women are no longer eligible for WIC.
(2) Breastfeeding women ("Some Breastfeeding") accepting formula for their infants in amounts that exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants. At six months postpartum, the breastfeeding women in Food Package VI will no longer be issued supplemental foods but do remain eligible for WIC. Such women may remain on the WIC Program as breastfeeding participants and receive nutrition education and breastfeeding support if in a current certification (up until they discontinue breastfeeding or their infants reach age 12 months, whichever happens first).
Food Package VI consists of milk, cheese, cereal, juice, eggs, fruits and/or vegetables, beans/peas or peanut butter. Refer to Attachment FP-27 for the authorized foods and the maximum amounts allowed per month for women.
C. Food Package VII is for four categories of women:
(1) Breastfeeding women up to one year postpartum whose infants do not receive any formula or medical foods from WIC ("Exclusively Breastfeeding Women"). These women are assumed to be exclusively breastfeeding their infants.
(2) Women who are pregnant with two or more fetuses ("Prenatal with Multiples").
(3) Women who are mostly breastfeeding multiple infants ("Mostly Breastfeeding Multiples").

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(4) Food Package VII also includes a "super" food package for women exclusively breastfeeding multiple infants ("Exclusively Breastfeeding Multiples"). None of the infants of a woman in this classification can receive any formula or medical foods from the WIC Program in order for the woman to qualify for this "super" food package. This package contains 1.5 times the amount of foods in the standard Food Package VII. Each of these "super" food packages consists of two monthly packages that are issued in alternating months. The rotation is done automatically by the computer system.
Food Package VII consists of milk, cheese, cereal, juice, eggs, whole grain bread or alternative, fruits and/or vegetables, beans/peas, peanut butter and fish. Refer to Attachment FP-27 for the authorized foods and the maximum amounts allowed per month for women.
D. Tailoring
It is federally mandated that the maximum monthly allowance be prescribed. This applies even where there are two (2) or more family members participating on the WIC Program.
The CPA can assign a standard package or a package with an alternative dairy option such as goat milk, tofu, or soy milk.
E. Food Package Assignment
The food packages for women are listed on Attachments FP-9 to FP-12. The Food Package Codes (FPCs) for Prenatal and Mostly Breastfeeding Women are W00 W21. The FPCs for Postpartum Non-Breastfeeding/ Fully Formula Feeding and Some Breastfeeding Women are W20 W41. The FPCs for Exclusively Breastfeeding Women are W40 W79.
The food package assigned to a breastfeeding mother is determined by the food package her infant(s) is receiving. If at any time the mother requests an additional amount of formula, the CPA should reassess the mother/baby pair to determine what changes need to be made to both the mother's and the infant's food package and feeding type. CPAs must change both the food package of the mother and infant(s) to reflect any changes in their joint status; for example, transitioning from Exclusively Breastfeeding to Mostly Breastfeeding or from Mostly Breastfeeding to Some Breastfeeding. Refer to Attachment FP-27 for the authorized foods

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and the maximum amounts allowed per month for women.
F. Manual Food Package
When Voucher Printing on Demand (VPOD) is not available, a manual food package should be issued. If a manual food package is not available for the food package the woman receives, then a food package should be issued using blank vouchers.
The standard food package for Prenatal and Mostly Breastfeeding Women is W01. For Non-Breastfeeding/Fully Formula Feeding Women and Some Breastfeeding Women the standard food package is W21. It is W41 for Exclusively Breastfeeding Women.
G. WIC Foods
1. Juice
Women have a choice of three forms of juice frozen concentrate, pourable concentrate, or 46 to 48 oz containers of single strength juice.
2. Milk
Only low-fat milk is allowed for women. Women in Food Package V or VII have a choice of two standard packages one with cheese and one without cheese. The package containing cheese also contains one box of dry powder milk in order to provide the full nutritional benefit mandated by federal regulations. If the participant does not want the dry powder milk, the clinic has two options: (a.) Issue the food package without cheese (all milk), or (b.) Create a 999 food package using state-created vouchers,
and replace the voucher containing dry powder milk (voucher codes W01 and W06) with one containing an equivalent quantity of evaporated milk (voucher codes #W67 or #W68, respectively).
The standard food package for women in Food Package VII contains cheese.

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3. Fish
Women receiving Food Package VII receive 30 ounces of fish (tuna or salmon). Women in Food Package V or VI are not authorized to receive fish.
4. Beans/Peas and Peanut Butter
Canned beans/peas may be substituted for dried beans/peas at the rate of 64 oz. of canned for one (1) pound of dried beans/peas. Issuance of additional combinations of dried or canned beans/peas and peanut butter is authorized as listed below: (a) 1 pound of dried plus 64 oz. of canned beans/peas (and
no peanut butter) (b) 2 pounds of dried beans/peas (and no peanut butter) (c) 128 oz. of canned beans/peas (and no peanut butter) (d) 2 containers (16-18 oz. each) of peanut butter (and no
beans/peas)
5. Fruits and Vegetables: The fruit and vegetable voucher cannot be counted when prorating vouchers. If the participant receives any voucher for the month, she must receive the fruit and vegetable voucher.
6. Other WIC Foods: For information on package sizes and restrictions see the Georgia Approved Foods List (Attachment FP-41).

H. Milk Alternatives
For women, cheese, calcium-set tofu, or soy milk may be substituted for milk as described below.
Cheese: Cheese may be substituted for milk at the rate of one (1) pound of cheese for 3 quarts of milk. A maximum of one (1) pound of cheese may be substituted in this manner without medical documentation of a qualifying medical condition for Food Packages V and VI. No more than two (2) pounds of cheese may be substituted for milk for Food Package VII recipients. With medical documentation women receiving Food Package VI may receive up to four (4) pounds of cheese and women

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receiving Food Package V and VII may receive up to six (6) pounds of cheese.
Soy Milk: Soy milk may be substituted for milk at the rate of 1 quart of soy milk for 1 quart of milk up to the total maximum monthly allowance of milk. Women are not required to have medical documentation in order to receive soy milk. Please note, soy-based beverages are not recommended for women with breast cancer.
Tofu: Calcium-set tofu may be substituted for milk at a rate of one (1) pound of tofu for 1 quart of milk. Medical documentation is required for women to receive more than four (4) pounds or six (6) pounds of tofu per month, depending on their category, feeding method and number of infants being carried or breastfed. With medical documentation women may receive up to 12 pounds of tofu. There are state-created vouchers containing tofu. If a different amount of tofu is needed, then a 999 food package will need to be developed using state-created vouchers.
I. Additional Documentation

CPAs must thoroughly document any situation in which less than the full maximum allotment of a supplemental food is issued to a participant (e.g., at the participant's request, due to a food allergy, etc.).
Medical documentation is required in the following situation:
Any authorized cheese or tofu issued to women that exceeds the maximum substitution rate.

VII. HOMELESSNESS, MIGRANCY, AND DISASTER SITUATIONS A. Alternative Food Package Assignment Local agencies have the option to convert participants to an alternative food package under the following circumstances: 1. A participant lacks a fixed and regular nighttime residence.
2. A participant's primary nighttme residence is:

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a. A publicly or privately operated shelter designed to provide temporary living accommodations.
b. A temporary accommodation in the residence of another individual.
c. A public or private place not designed for or ordinarily used as a regular sleeping accommodation.
3. A participant's primary residence lacks refrigeration and/or contains a contaminated or limited water supply.

4. In disaster situations such as floods, tornadoes, etc., that temporarily displace participants from their normal residences or that result in an unsafe water supply.

B. Food Package Assignment
The CPA must reevaluate and assign appropriate food packages when the participant locates a permanent residence with adequate refrigeration and/or a safe water supply.
C. Manual Food Package
When Voucher Printing on Demand (VPOD) is not available, a manual food package should be issued when possible. If a manual food package is not available that will meet the participant needs, then a food package should be issued using blank voucher(s).
D. Assignment of Food Package Codes
1. Infants
a. Alternative food packages for infants consist of 8 oz containers of ready-to-feed formula.
(1) Contract milk-based formula: CPA FPC is A10.
(2) Contract soy-based formula: CPA FPC is A20.
b. Each infant CPA Food Package Code (FPC) represents three packages - one for each infant age group (0 through 3 months, 4 through 5 months, and 6 through 11 months.)

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A different amount of formula is allowed for each age group. Infants 4 through 5 months receive slightly more formula than do the infants 0 through 3 months old. Infants 6 through 11 months old receive less formula and the addition of baby cereal and infant food fruits and vegetables.
Georgia computer systems are automated to progress the infant through these three age groups. The CPA FPCs for Fully Formula Fed (FFF) infant packages start with an "A." The computer will issue internal food packages beginning with a "B" to infants ages 4 through 5 months, and packages beginning with "D" to infants ages 6 through 11 months. For maximum amounts see Attachment FP-21 for infant food and FP-28 for alternative formula.
2. Children 1 To 5 Years
Alternative food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, vitamin C fortified juice, fruits and vegetables, whole grain bread or alternative and canned beans or peanut butter. The food package codes for children's alternative packages are C10 and C30. For maximum amounts see Attachment FP-28.
3. Pregnant and Breastfeeding Women
Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100% vitamin C fortified juice, fruits and vegetables, whole grain bread or alternative, canned beans and/or peanut butter. Food package W10 may be assigned to pregnant and Mostly Breastfeeding women. The alternative package for Exclusively Breastfeeding women is W50. For maximum amounts see Attachment FP-28.
4. Non-Breastfeeding Women
Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100% vitamin C fortified juice, fruits and vegetables, canned beans and/or peanut butter. The alternative package for women Breastfeeding Some (SBF) and

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Non- Breastfeeding women is W30. For Maximum amounts see Attachment FP-28.

VIII. MEDICAL DOCUMENTATION
No medical foods, formulas requiring a prescription, supplemental foods (for clients in Food Package III), or special milk substitutions requiring medical documentation may be issued to a participant without appropriate medical documentation, as outlined below. Participants with expired medical documentation cannot be issued any vouchers until either verbal or written medical authorization is obtained.
WIC-Approved formulas designed for enteral feeding (i.e., tube feeding) may be authorized. However, the WIC Program does not authorize distribution of formulas designed for parenteral (i.e., intravenous) infusion. All apparatus, equipment, or devices (e.g., enteral feeding tubes, bags and pumps) designed to administer WIC formulas are not allowable WIC costs.
A. Situations Requiring Medical Documentation
1. Infants: a) Issuance of a contract brand infant formula requiring a prescription. b) Issuance of a Georgia WIC approved non-contract brand infant formula. c) Issuance of any Georgia WIC approved exempt infant formula or medical food.
2. Children: a) Issuance of any Georgia WIC approved infant formula, exempt infant formula, or medical food. b) Issuance of any quantity of soy milk or tofu. c) Issuance of more than one (1) pound of cheese per month.
3. Women: a) Issuance of any Georgia WIC approved formula, exempt formula, or medical food. b) Issuance of more than one or two (1 or 2) pounds of cheese per month.* c) Issuance of more than four or six (4 or 6) pounds of tofu per month.*
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*Note: The exact quantity depends upon a woman participant's category, the number of infants she is pregnant with or has just delivered, and her infant feeding method.

B. Acceptable and Unacceptable Forms of Documentation
1. Clinics may accept medical documentation in the form of an original written document, an electronic document, or medical documentation received by facsimile or telephone. Verbal orders received by telephone must be followed with written documentation (original, electronic, or faxed) within 2 weeks of the original verbal order. Please refer to Section D below for verbal order procedures.
2. Medical documentation must be written on a physician's prescription pad, private medical office letterhead, District/County letterhead, or on one of the two Georgia WIC Program forms described below.
3. Clinics are encouraged to promote the use of the Georgia WIC Program medical documentation forms to reduce the likelihood of missing information when other forms are used. It is not mandatory for the health care providers to use the Georgia WIC Program medical documentation forms, but other forms described in #2 above must contain all of the required information described in this section. The Georgia WIC Program medical documentation forms are: a) Medical Documentation Form for WIC Special Formula and Approved WIC Foods (Form #1). This form is for prescribing formulas and medical foods. Please refer to Attachment FP-37 for a copy of the form and complete instructions on form use. b) Referral Form and Medical Documentation for Special Food Substitutions (Form #2). This form is for providing referral data and for authorizing special milk substitutions requiring medical documentation (e.g., tofu, extra cheese, soy milk). Please refer to Attachment FP-39 for a copy of the form and complete instructions on form use.
4. Georgia WIC clinics may not accept the following forms: a) Prescription forms or prescription pads which are preprinted or pre-stamped with a formula requiring a

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prescription. b) Forms or prescription pads containing formula
advertising. c) Prescription pads or forms that include a pre-printed list
of formulas from which the healthcare provider is expected to choose are not allowed. For example, a prescription form that lists 10 common special formulas and one blank "other" formula option with a check box next to each is unacceptable. The prescription pad or form must not contain any pre-printed or "suggested" formulas.
C. Required Medical Documentation Components
1. The complete brand name of the authorized WIC formula prescribed and the amount of formula needed per day.
2. The authorized supplemental food(s) appropriate for the qualifying medical condition(s) and any restrictions.
3. The length of time the prescribed WIC formula is required by the participant.
4. The qualifying medical condition(s) requiring the issuance of the authorized WIC formula.
5. The original signature, date, and contact information of the authorized prescribing health care provider.
a) Medical documentation must contain the original signature of a health care professional licensed by the State of Georgia to write prescriptions in accordance with state laws. Stamped or pre-printed signatures will not be accepted. However, electronic signatures are acceptable. Medical documentation for Georgia WIC may only be signed by the following healthcare providers: Physicians (e.g., MD, DO) Nurse Practitioners (e.g., APRN, NP, CPNP, CNP, PNP, CNNP, FNP) Physician Assistants (e.g., PA, PA-C)

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b) Prescriptions signed by any other health professionals cannot be accepted. Registered Dietitians (RDs), including those with advanced certifications such as certified nutrition support dietitians (CNSDs) and dietitians who are board certified specialists in pediatric nutrition (e.g., CSPs), cannot sign prescriptions for WIC. Although such dietitians are experts in their respective areas of specialization, they do not have prescriptive authority in the State of Georgia and therefore cannot sign prescriptions for use in the WIC Program as outlined by federal regulations.
D. Verbal Orders
1. For Participants Without Any Medical Documentation
a) Written medical documentation or a verbal order from an authorized healthcare provider is required prior to food package assignment by the WIC CPA.
b) Verbal orders must only be received and documented by a CPA.
c) The CPA must promptly document the verbal order. Document the details of the verbal order in the participant's paper or electronic WIC record (including all medical documentation components required in Section C above) and sign/date the information. The complete name and credentials (e.g., MD or NP) of the authorized prescribing health care provider is to be recorded in place of his/her original signature.
d) Confirmation of a verbal order must be requested from the health care provider and must be received within 2 weeks of the initial verbal order.
e) Only one (1) month of vouchers may be issued to a participant when a verbal order is received. Do not issue a second month of vouchers until the written documentation is received by the clinic. Medical documentation must be written and may be provided as an original written document, an electronic document, or by facsimile.
f) All medical documentation must be kept on file at the local clinic.

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2. For Participants With Incomplete Medical Documentation
a) Verbal orders also may be accepted by a CPA to complete minor missing or incomplete information on Form #1 or Form #2. For example: 1. A missing ICD-9 code (when the name of the diagnosis is already recorded on the form) 2. To clarify the full formula product name (e.g., did "Neocate" mean Neocate Infant, Neocate Infant DHA + ARA, Neocate Junior, or Neocate One+?) 3. A missing product form (powder, concentrate, or readyto-feed) 4. A missing "planned length of use" 5. A missing zip code or fax number
b) The CPA must document the missing information on the form, initial and date each change, and record the name and credentials of the physician, physician assistant, or nurse practitioner who gave the verbal authorization by each change. A new medical documentation form does not need to be completed. 1. If extensive information is missing or if any information needs to be corrected or revised, the health care provider must complete a new form. 2. If the health care provider's signature is missing, was completed using a "signature stamp," or if the form was signed by an unauthorized provider, a new form must be completed. 3. This process cannot be used in place of the "verbal order" procedures outlined above for use when no medical documentation exists (i.e., instead of getting written medical documentation from a health care provider). This process must only be used to add minor missing information to an existing form.
c) In this instance, the participant may be issued the full set of vouchers once the missing/incomplete information is obtained and fully documented by the CPA.
E. Frequency and Records
1. Current medical documentation is required, at a minimum, every six (6) months, with any change in the order, and at every recertification/sub-certification/mid-certification* for the prescription of special formulas and medical foods on Form #1.

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2. Current medical documentation is required, at a minimum, every six (6) months, with any change in the order, and at every recertification/sub-certification/mid-certification* for the prescription of special milk substitutions on Form #2.
*Note: If the medical documentation on file was signed and dated by the health care provider more than 30 days prior to the date of the recertification/subcertification/mid-certification, then new medical documentation must be provided by the client.
3. Current medical documentation is defined as medical documentation that was signed and dated by the health care provider less than or equal to 30 days of being received by the WIC staff (i.e., within the past 30 days).
4. All medical documentation must be kept on file at the local clinic.

F. Issuance of Ready-To-Feed Products
Local agencies must issue all WIC formulas (all infant formula, exempt infant formula and WIC-eligible medical foods) in concentrated liquid or powder physical forms. Ready-to-feed WIC products may be authorized when the CPA determines and documents that: 1. The participant's household has an unsanitary or restricted water
supply or poor refrigeration; 2. The person caring for the participant may have difficulty in
correctly diluting concentrated or powder forms; or 3. The formula is only available in a ready-to-feed form. 4. In addition, participants with qualifying medical conditions who
are assigned to Food Package III can also be issued ready-to-feed formulas for the additional reasons below: If the ready-to-feed form better accommodates the
participant's medical condition (Food Package III clients only); or If the ready-to-feed form improves the participant's compliance in consuming the prescribed formula (Food Package III clients only).
Use of either of these two additional reasons must be clearly documented by the CPA in the participant's paper or electronic WIC record. These two reasons are only applicable for participants who have medical documentation on Form #1 and who meet the below criteria:

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1. Infants must be prescribed an exempt infant formula or medical food on Form #1. Infants who are receiving a standard contract/non-contract infant formula requiring a prescription are not eligible for Food Package III, and therefore are not eligible to receive ready-to-feed products for the above two additional reasons. Examples of ineligible products include Similac Sensitive, Similac Sensitive R.S., Similac Go & Grow products, Enfamil ProSobee LIPIL, Enfamil Soy LIPIL, Enfagrow Soy, Enfamil A.R. LIPIL, Nestl Good Start Soy PLUS, Nestl Good Start Soy PLUS 2, and Parent's Choice Soy.
a) Children or women may be prescribed any infant formula, exempt infant formula, or medical food on Form #1 to qualify for the two additional ready-to-feed options.
G. Medical Diagnoses
1. Non-specific, general medical diagnoses are not sufficient for the purpose of WIC prescriptions. The below list of unacceptable diagnoses is not all-inclusive. WIC clients with prescriptions containing the below diagnoses may need additional documentation or a more specific diagnosis. Please contact the prescribing health care professional for a more specific, updated prescription. If a prescription includes more than one diagnosis (including one of those listed below), the other listed diagnosis(es) may be sufficient for approval. CPAs should use their professional judgment or contact their Nutrition Manager for guidance. The below diagnoses are not permitted for use as the sole diagnosis on WIC prescriptions:
"Milk intolerance" or "formula intolerance" (e.g., sometimes ICD-9 code 579.8 is used)
"Severe milk allergy" or "milk allergy" "Multiple food allergies" "Feeding difficulties" or "feeding problems" (e.g., 783.3,
779.3) "Colic," "fussiness," "constipation," "gas," or "cramps"
(e.g., 787.3, 789.0, 780.91, 780.92) "Spitting up" "Digestive disturbances" "Picky eater," "poor appetite," or "inadequate/poor
intake"

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Insufficient Diagnosis "783.3" "Feeding problems" "Spitting up" "Formula intolerance"

Sample Acceptable Alternative Diagnosis/Diagnoses "Feeding problems (783.3), CP, NG-tube" "Oral-motor feeding disorder 783.40" "GERD/reflux 530.81" "Cow's milk protein intolerance" or "malabsorption syndrome NOS" (e.g., 558.3, 579.8, 579.9, 693.1)

2. The following diagnoses require an underlying medical condition be present and documented:
a) "Underweight" or "inadequate/poor weight gain" b) "Feeding disorder" c) "Inadequate/poor growth"
The Georgia WIC Program cannot accept these diagnoses alone a more specific, primary medical condition must be present and listed among the diagnoses (e.g., Cerebral Palsy, Failure-to-Thrive, Oral-Motor Feeding Disorder, Prematurity, Dysphagia, etc.).
3. Medical diagnoses must be consistent with the participant's anthropometric data (e.g., length/height, weight, BMI). CPAs should use their professional judgment and, if needed, seek additional guidance from their Nutrition Managers or Nutrition Services Directors. For example: a) A diagnosis of "Failure to Thrive/FTT" for a child whose BMI is at the 75th percentile or above should be questioned. b) A diagnosis of "Food Aversion" for a child whose BMI is above the 50th percentile and whose caregiver reports that the child eats chips, candy, junk food, and sweets all day but refuses healthier foods should be questioned. c) A diagnosis of "Food Aversion" for a child whose BMI is below the 25th percentile and who is receiving therapy (e.g., speech, physical, or occupational therapy) need not be questioned.
4. Medical diagnoses must be consistent with the formula or medical food prescribed. CPAs should use their professional judgment and, if needed, seek additional guidance from their Nutrition Managers or Nutrition Services Directors. For example:
a) "Lactose intolerance" should not be accepted as a diagnosis if the product prescribed contains lactose.

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b) A diagnosis of "GERD" is not an appropriate diagnosis for the issuance of PediaSure or Boost Kid Essentials.
c) "Milk protein allergy" is not an appropriate diagnosis for the issuance of a milk-based formula or medical food.
5. See Attachment FP-14 for Medical Documentation Form (Form 1) and Referral Form (Form 2).

IX. FORMULA DISTRIBUTION/TRACKING GUIDELINES
Local agency procedures for tracking formula returned to the clinic for various reasons and tracking formula received and distributed related to special formula ordered through the Office of Nutrition (See Attachment FP-42).
A. Reasons to Issue Formula
See the Formula Distribution / Tracking Guidelines table below for guidance on allowable and non-allowable reasons for issuing formula.

Formula Distribution / Tracking Guidelines
(Returned Formula)

Allowable reasons to issue Formula:

Non-allowable reasons to issue Formula:

x Trading formula- 1 for 1 trade of returned formula (based on equivalent quantity of reconstituted formula). Issuance may include a combination of vouchers and formula.
x Food Package Change
x Error in purchase
x Damaged Formula
x Clinic error with appointment given
x Adjusting pick up code for family
x Disaster situations: Fire, flood etc.
x Partial or full issuance as Food Package

x Pre-certification issuance of formula to last until scheduled appointment
x Client missed recertification appointment x For client to try out another formula to
determine if it is better tolerated x Participant reporting lost or stolen vouchers x Client running out of formula x Distribution to non-WIC clients

*Document returned formula on the Formula Tracking Log (Attachment FP-42). All formula must be accounted for when issued to a client or destroyed.

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B. Maximum Amount to be Issued. Not to exceed the maximum monthly amounts authorized for the participant category in question.

C. Documentation. Documentation of issuance must be written on the Formula Tracking Log (Attachment FP-42). When applicable, also document issuance in the client's health record.
a. Formula Tracking Log: Formula issued to a WIC client or destroyed must be documented on the Formula Tracking Log (Attachment FP-42).

b. WIC client's health record: If a detailed medical explanation is needed (i.e., transition from one formula to another), document the quantity of formula issued, type of formula, reason for issuance and signature of individual issuing the formula.

D. Disposal of Expired Formula. Expired formula should be opened and disposed of properly. Document expired formula that was disposed of on the Formula Tracking Log.

X. OFFICE OF NUTRITION SPECIAL FORMULA ORDERS
When ordering special formulas through the Office of Nutrition the "Special Formula Order Form" (Attachment FP-33) should be used. A fillable version of the "Special Formula Order Form" is also available on the Georgia WIC website listed below. The fillable order form can be completed online, saved, printed, signed, and then faxed to Office of Nutrition (404-657-2886) along with the client's medical documentation. Also calling to alert staff of in-coming fax is helpful. In addition, the link contains a copy of the ordering procedures and a copy of the current WIC Approved Formulas/Medical Foods List.
Web resources for special formula ordering: http://health.state.ga.us/programs/wic/wicformula.asp (under "Procurement of Special Formula" link)
A. Ordering
The Office of Nutrition can only order special formula in whole case quantities from the manufacturers. This will often result in the District/clinic receiving more formula than was ordered and more

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formula than is allowed to be issued to a client. When a District/clinic receives a formula order, issue only the prescribed amount of formula to the client (up to the maximum allowed). Do not automatically give a client all of the formula that was delivered, since that will usually result in overissuance.
B. Tracking Log
Districts/clinics are responsible for tracking the additional partial cases of formula received in the appropriate Formula Tracking Log. Such leftover formula must be taken into consideration when determining how much special formula to request on subsequent special formula orders. Leftover formula one month indicates that less formula will need to be requested from the Office of Nutrition the following month. Document request for
formula and distribution in participant's health record.
C. Amount to Order
When completing the "Special Formula Order Form," Districts/clinics must specify in Line #6 the exact number of cans/containers of special formula needed for that client for that issue month (taking into consideration any leftover formula on hand, the prescribed quantity, the maximum allowed for the client category [infant, child, woman], the maximum allowed for infants [if applicable] based on infant age and infant feeding type, and the product type [powder, concentrate, ready-tofeed]). The Office of Nutrition will convert the number of cans/containers to case quantities for the order. Please do not simply write "max. allowed," "9 cases," or enter the same quantity of formula each month (e.g., "10 cans"). Districts/clinics are encouraged to maintain a spreadsheet(s) to track the special formula orders submitted for their participants in addition to tracking leftover partial cases of formula in the applicable Formula Tracking Log. Please refer to Attachment FP-34 for a sample tracking document.
For infant participants, please enter the infant's age on the "Special Formula Order Form" as of the "First Day To Use" date on the vouchers for the current issuance month. The infant's age should be documented in months and days to ensure that the correct amount of formula is being requested based on the infant's age.
Remember to use the correct charts to determine maximum formula allowed if you are ordering formula for an infant who is also being breastfed.

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D. Special Formula Order Form
Districts/clinics should complete and submit the "Special Formula Order Form" each month for each client allowing for realistic shipping time. Orders can be shipped overnight, if necessary, for new clients. However, ongoing orders for existing special formula clients should be submitted at least 7-10 business days prior to the date the formula is needed for pick-up by the client to ensure sufficient processing time. Special formula orders should not routinely be requested for "rush" delivery due to the additional fees often charged for expedited delivery. All efforts will be made by state staff to ensure timely delivery of special formula for WIC clients. However, since WIC is a supplemental program, caregivers may need to purchase some formula in the interim. Under routine circumstances, an order should be received within 5 business days of placing the order.
E. Frequency
The Office of Nutrition only accepts orders for a one-month supply of any special formula(s) at a time for a client. Please do not submit requests for multiple months' worth of formula on one order form or submit several orders covering several months at one time. Many clients on special formulas frequently change formulas and/or food packages.
F. Medical Documentation
Districts/clinics must include current medical documentation with each special formula order submitted each month.
G. Printing Tracking Voucher
Districts/clinics must print a 199 food package each month a client is issued formula is ordered through the Office of Nutrition. This tracking voucher allows the client to be counted in the clinic caseload. Failure to do so underreports your District caseload.
H. Flavor
Specify product flavor(s), when applicable, on the Special Formula Order Form every month.

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I. Processing the Order
After the order is received and verified as correct and complete the packing slip should be signed and dated. The special order packing slip should then be returned to Office of Nutrition; Mail: 2 Peachtree Street NW, Suite 11-222, Atlanta, GA, 30303-3142 Fax: 404-657-2886
Notify the Office of Nutrition immediately if an incorrect order is delivered, or if there is a change in the formula order.
The food package code for all WIC types for special formulas ordered through Office of Nutrition is 199. When the CPA assigns food package 199 a second field will be enabled in the computer system to allow the CPA to select a food package for the appropriate supplemental foods or additional formula based on the medical documentation provided. The food package could be a child or woman's state-created food package or a 999 food package if none of the standard state-created food packages meet the medical food prescription. The special formula food package must be entered into the computer as the first food package code to enable the second field.
If the WIC participant only needs the "199" food package, enter "000" in the second food package box to indicate that additional foods do not need to be issued.
For infants receiving a "199" food package needing to be issued infant fruits and vegetables and/or cereal enter 999 in the second box and select appropriate voucher codes.

XI. EMORY GENETIC WIC CLIENTS
Under the State of Georgia's newborn screening program, all infants are screened for specific metabolic and genetic conditions. The Emory Genetics program is responsible for following up on all infants who have positive screenings. In most cases Emory Genetics also provides ongoing medical services including highly specialized nutritional management to those individuals with diagnosed metabolic or genetic disorders.
The Georgia WIC Program has an agreement that permits Emory Genetics to provide WIC-approved formulas and medical foods to active WIC clients. The Georgia WIC food package system allows a WIC clinic to issue a special "Emory

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Genetics food package" or food package 099 to WIC clients who are under the medical care of Emory Genetics. Emory Genetics provides the prescribed formula or combination of formulas to each of their WIC clients monthly and then submits a report to the Georgia WIC Program requesting reimbursement for the formulas provided (up to the maximum monthly formula amounts authorized per client according to WIC regulations).
A. Emory Genetics Prescriptions
When WIC clients present Emory Genetics prescriptions to their WIC clinics, special precautions must be taken to reduce the likelihood of overissuance of formula.
Emory Genetics clients should be issued a 099 food package to cover the formula issued by Emory Genetics. Emory Genetics will provide the WIC clinic with medical documentation on which, if any, supplemental foods are allowed.
The WIC clinic must print the Emory Genetics food package for each issuance month based on the client's pick-up code. Follow the instructions on each voucher. Have the client sign the voucher receipt(s).
The WIC clinic will then fax the "Emory Genetics Copy" voucher (voucher code #299) for each month to the fax number listed on the voucher. Do not complete the "Formula Name" or "Cost" lines on the voucher; those lines are for Emory Genetics use. Retain the "Emory Genetics Copy and "Chart Copy" vouchers in the client's medical record or WIC chart. Provide the "Client Copy" to the client/caregiver.
B. Provision of Formula and WIC Foods
Do not issue any formula to an Emory Genetics WIC client. WIC clinics should not print any vouchers containing formula or provide any formula from stock on hand to an Emory Genetics WIC client. Emory Genetics provides all of the formula to the WIC client and then invoices the state for the allowable amount of formula based on WIC policies. Clinics that issue any formula to their Emory Genetics WIC clients increase the chances of formula over-issuance. Districts can be held financially responsible for repaying the Georgia WIC Program for such over-issuance errors.
The clinic will issue any supplemental foods Emory Genetics has prescribed. If supplemental foods are authorized, enter the appropriate

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state-created special food package code on the 2nd FPC field in the computer system. If none of the state created food packages match the participant's prescription enter 999 and create a 999 food package using state-created vouchers for individual supplemental foods. If the client is not approved to receive any supplemental foods enter 000 in the second food package box.
C. Breastfeeding
If an infant receiving formula from Emory Genetics is also being breastfed, be sure the medical documentation includes enough information for you to assign the correct feeding type for the infant and their mother.

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1

Formula Summary Standard Formulas for Infants and Children

CPA FPC A12
F12
X12 A11
F11
E11 K11 J11 X11 A13
F13

Status / Age
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
MB 1-3 m MB 4-5 m MB 6-11 m

System FPC
A12 B12 D12
F12 G12 H12
X12
A11 B11 D11
F11 G11 H11
E11 L11
K11 M11
J11 N11
X11
A13 B13 D13
F13 G13 H13

Formula
Concentrate Similac Advance EarlyShield 31-13 oz cans concentrate Similac Advance EarlyShield 34-13 oz cans concentrate Similac Advance EarlyShield 24-13 oz cans concentrate Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 14-13 oz cans concentrate Similac Advance EarlyShield 17-13 oz cans concentrate Similac Advance EarlyShield 12-13 oz cans concentrate Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz cans concentrate Similac Advance EarlyShield
Powder Similac Advance EarlyShield 9-12.9 oz cans powder Similac Advance EarlyShield 10-12.9 oz cans powder Similac Advance EarlyShield 7-12.9 oz cans powder Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.9 oz cans powder Similac Advance EarlyShield 5-12.9 oz cans powder Similac Advance EarlyShield 4-12.9 oz cans powder Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.9 oz powder Similac Advance EarlyShield 1-12.9 oz powder Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.9 oz powder Similac Advance EarlyShield 2-12.9 oz powder Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.9 oz powder Similac Advance EarlyShield 3-12.9 oz powder Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-12.9 oz cans powder Similac Advance EarlyShield
RTF Similac Advance EarlyShield 26-32 oz RTF container Similac Advance EarlyShield 28-32 oz RTF container Similac Advance EarlyShield 20-32 oz RTF container Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF container Similac Advance EarlyShield 14-32 oz RTF container Similac Advance EarlyShield 10-32 oz RTF container Similac Advance, 32 jars baby

FP-48

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1 (cont'd)

CPA FPC X13 A10
X10 A22
F22
X22 A21
F21
E21 K21 J21 X21 A23

Status / Age
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m
MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m

System FPC
X13
A10 B10 D10
X10
A22 B22 D22
F22 G22 H22
X22
A21 B21 D21
F21 G21 H21
E21 L21
K21 M21
J21 N21
X21
A23

Formula
fruit/vegetable, 3-8 oz box infant cereal 28-32 oz RTF container Similac Advance EarlyShield
RTF Similac Advance EarlyShield alternative 104-8oz RTF container Similac Advance EarlyShield 112- 8 oz RTF container Similac Advance EarlyShield
80 - 8oz RTF container Similac Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 108-8oz RTF container Similac Advance EarlyShield
Concentrate Isomil Advance 31-13 oz cans concentrate Isomil Advance 34-13 oz cans concentrate Isomil Advance 24-13 oz cans concentrate Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 14-13 oz cans concentrate Isomil Advance 17-13 oz cans concentrate Isomil Advance 12-13 oz cans concentrate Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz cans concentrate Isomil Advance
Powder Isomil Advance 9-12.9 oz cans powder Isomil Advance 10-12.9 oz cans powder Isomil Advance 7-12.9 oz cans powder Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.9 oz cans powder Isomil Advance 5-12.9 oz cans powder Isomil Advance 4-12.9 oz cans powder Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.9 oz powder Isomil Advance 1-12.9 oz powder Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.9 oz powder Isomil Advance 2-12.9 oz powder Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.9 oz powder Isomil Advance 3-12.9 oz powder Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-12.9 oz cans powder Isomil Advance
RTF Isomil Advance 26-32 oz RTF container Isomil Advance

FP-49

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1 (cont'd)

CPA FPC
F23
X23 A20
A32
F32
X32 A31
F31
E31 K31 J31

Status / Age FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m

System FPC B23 D23
F23 G23 H23
X23
A20 B20 D20
A32 B32 D32
F32 G32 H32
X32
A31 B31 D31
F31 G31 H31
E31 L31
K31 M31
J31

Formula
28-32 oz RTF container Isomil Advance 20-32 oz RTF container Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF container Isomil Advance 14-32 oz RTF container Isomil Advance 10-32 oz RTF container Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz RTF container Isomil Advance
RTF Isomil Advance alternative 104-8oz RTF container Isomil Advance 112- 8 oz RTF container Isomil Advance 80 - 8oz RTF container Isomil Advance, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
Concentrate Similac Sensitive 31-13 oz cans concentrate Similac Sensitive 34-13 oz cans concentrate Similac Sensitive 24-13 oz cans concentrate Similac Sensitive , 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 14-13 oz cans concentrate Similac Sensitive 17-13 oz cans concentrate Similac Sensitive 12-13 oz cans concentrate Similac Sensitive , 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz cans concentrate Similac Sensitive
Powder Similac Sensitive 9-12.9 oz cans powder Similac Sensitive 10-12.9 oz cans powder Similac Sensitive 7-12.9 oz cans powder Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.9 oz cans powder Similac Sensitive 5-12.9 oz cans powder Similac Sensitive 4-12.9 oz cans powder Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.9 oz powder Similac Sensitive 1-12.9 oz powder Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.9 oz powder Similac Sensitive 2-12.9 oz powder Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.9 oz powder Similac Sensitive

FP-50

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1 (cont'd)

CPA FPC X31 A33
F33
X33 A41
F41
E41 K41 J41 X41 A43
F43

Status / Age
MB 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m

System FPC N31
X31
A33 B33 D33
F33 G33 H33
X33
A41 B41 D41
F41 G41 H41
E41 L41
K41 M41
J41 N41
X41
A43 B43 D43
F43 G43

Formula
3-12.9 oz powder Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-12.9 oz cans powder Similac Sensitive
RTF Similac Sensitive 26-32 oz RTF container Similac Sensitive 28-32 oz RTF container Similac Sensitive 20-32 oz RTF container Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF container Similac Sensitive 14-32 oz RTF container Similac Sensitive 10-32 oz RTF container Similac Sensitive, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz RTF container Similac Sensitive
Powder Similac Sensitive RS 9-12.9 oz cans powder Similac Sensitive RS 10-12.9 oz cans powder Similac Sensitive RS 7-12.9 oz cans powder Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.9 oz cans powder Similac Sensitive RS 5-12.9 oz cans powder Similac Sensitive RS 4-12.9 oz cans powder Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.9 oz powder Similac Sensitive RS 1-12.9 oz powder Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.9 oz powder Similac Sensitive RS 2-12.9 oz powder Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.9 oz powder Similac Sensitive RS 3-12.9 oz powder Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-12.9 oz cans powder Similac Sensitive RS
RTF Similac Sensitive RS 26-32 oz RTF container Similac Sensitive RS 28-32 oz RTF container Similac Sensitive RS 20-32 oz RTF container Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF container Similac Sensitive RS 14-32 oz RTF container Similac Sensitive RS

FP-51

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1 (cont'd)

CPA FPC
X43 D61 F61 X61
D71 F71 X71

Status / Age MB 6-11 m
Child
FFF 9-11 m MB 9-11 m
Child
FFF 9-11 m MB 9-11 m
Child

System FPC H43 X43 D61 F61 X61
D71 F71 X71

Formula
10-32 oz RTF container Similac Sensitive RS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz RTF container Similac Sensitive RS
Similac Go & Grow EarlyShield Milk-Based 4-22 oz cans powder Similac Go & Grow EarlyShield MilkBased, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-22 oz cans powder Similac Go & Grow EarlyShield MilkBased, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 5-22 oz cans powder Similac Go & Grow EarlyShield MilkBased
Similac Go & Grow Soy-Based 4-22 oz cans powder Similac Go & Grow Soy-Based, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-22 oz cans powder Similac Go & Grow Soy-Based, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 5-22 oz cans powder Similac Go & Grow Soy-Based

CPA FPN E00

Status / Age EBF 0-5 m EBF 6-11 m

Exclusively Breastfeeding Infant

System FPN

Exclusively Breastfeeding Infant

EOO Breastfeeding Message

E01 Breastfeeding Message, 64 jars baby fruit/vegetable, 31 jars

meat, 3-8 oz box infant cereal

FP-52

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1 (cont'd)

Formula Summary Non-Contract Formulas

CPA FPC A24
X24 A25
X25 A26
X26 D74 X91 A44
X44 A46

Status / Age
FFF 0-3 m FFF 4-5 m FFF 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
Child
FFF 9- 11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
Child FFF 0-3 m

System FPC A24 B24 D24 X24
A25 B25 D25 X25
A26 B26 D26 X26
D74 X91
A44 B44 D44 X44 A46

Formula
Powder Enfamil ProSobee LIPIL or Enfamil Soy LIPIL 9 12.9 oz cans Enfamil ProSobee LIPIL or Enfamil Soy LIPIL 10-12.9 oz cans Enfamil ProSobee LIPIL or Enfamil Soy LIPIL 7-12.9 oz cans Enfamil ProSobee LIPIL or Enfamil Soy LIPIL, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9 12.9 oz cans Enfamil ProSobee LIPIL or Enfamil Soy LIPIL Concentrate Enfamil ProSobee LIPIL or Enfamil Soy LIPIL 31-13 oz cans conc. ProSobee LIPIL or Enfamil Soy LIPIL 34-13 oz cans conc. ProSobee LIPIL or Enfamil Soy LIPIL 24-13 oz cans conc. ProSobee LIPIL or Enfamil Soy LIPIL, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz cans conc. ProSobee LIPIL or Enfamil Soy LIPIL
Ready to Feed Enfamil ProSobee LIPIL or Enfamil Soy LIPIL
26 32 oz cans RTF Enfamil ProSobee LIPIL or Enfamil Soy LIPIL 28 32 oz cans RTF Enfamil ProSobee LIPIL or Enfamil Soy LIPIL 20 32 oz cans RTF Enfamil ProSobee LIPIL or Enfamil Soy LIPIL, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28 32 oz cans RTF Enfamil ProSobee LIPIL or Enfamil Soy LIPIL
Powder Enfagrow Soy
4 24 oz cans powder Enfagrow Soy
5 24 oz cans powder Enfagrow Soy
Powder Enfamil AR LIPIL 9 12.9 oz cans powder Enfamil AR LIPIL 10-12.9 oz cans powder Enfamil AR LIPIL 7-12.9 oz cans powder Enfamil AR LIPIL, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9 12.9 oz cans powder Enfamil AR LIPIL
Ready to Feed Enfamil AR LIPIL 26 32 oz cans RTF Enfamil AR LIPIL

FP-53

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-1 (cont'd)

FFF 4-5 m

FFF 6-11 m

X46

Child

A28 FFF 0-3 m FFF 4-5 m

FFF 6-11 m

X28

Child

A27 FFF 0-3 m FFF 4-5 m

FFF 6-11 m

X27

Child

A29 FFF 0-3 m FFF 4-5 m

FFF 6-11 m

X29

Child

B46 28 32 oz cans RTF Enfamil AR LIPIL D46 20 32 oz cans RTF Enfamil AR LIPIL, 32 jars baby
fruit/vegetable, 3-8 oz box infant cereal X46 28 32 oz cans RTF Enfamil AR LIPIL
Concentrate Nestle Good Start Soy PLUS A28 31-13 oz cans Nestle Good Start Soy PLUS B28 34-13 oz cans Nestle Good Start Soy PLUS D28 24-13 oz cans Nestle Good Start Soy PLUS
32 jars baby fruit/vegetable, 3-8 oz box infant cereal X28 35-13 oz cans Nestle Good Start Soy PLUS Powder Nestle Good Start Soy PLUS A27 9-12.9 oz cans powder Nestle Good Start Soy PLUS B27 10-12.9 oz cans powder Nestle Good Start Soy PLUS D27 7-12.9 oz cans powder Nestle Good Start Soy PLUS, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal X27 10-12.9 oz cans powder Nestle Good Start Soy PLUS RTF Nestle Good Start Soy PLUS A29 26-32 oz cans RTF Nestle Good Start Soy PLUS B29 28-32 oz cans RTF Nestle Good Start Soy PLUS D29 20 32 oz cans RTF Nestle Good Start Soy PLUS, 32 jars baby fruit/vegetable, 3-8 oz cereal X29 28-32 oz cans RTF Nestle Good Start Soy PLUS

FP-54

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2

Contract Formulas

Infant Fully formula Fed

0 3 months

Similac Advance EarlyShield

Food Package Code

VC Voucher Message

A11

895 Formula 5-12.9 oz cans powder Similac

9-12.9 oz powder Similac

Advance EarlyShield

Advance EarlyShield

N59 Formula 4-12.9 oz cans powder Similac

Advance EarlyShield

A12

251 Formula 15-13 oz cans concentrate

3113 oz concentrate

Similac Advance EarlyShield

Similac Advance

252 Formula 16-13 oz cans concentrate

EarlyShield

Similac Advance EarlyShield

A13

007 Formula 13-32 oz containers ready to feed

26-32 oz ready-to-feed

Similac Advance EarlyShield

Similac Advance

007 Formula 13-32 oz containers ready to feed

EarlyShield

Similac Advance EarlyShield

A10-Alternative Package N58 Formula 24-8 oz containers ready to feed

Similac Advance EarlyShield

104-8 oz ready to feed

N58 Formula 24-8 oz containers ready to feed

Similac Advance

Similac Advance EarlyShield

EarlyShield

N58 Formula 24-8 oz containers ready to feed

Similac Advance EarlyShield

N58 Formula 24-8 oz containers ready to feed

Similac Advance EarlyShield

N53 Formula 8-8 oz containers ready to feed

Similac Advance EarlyShield

FP-55

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Food Package Code A21 9-12.9 oz powder Isomil Advance
A22 31-13 oz concentrate Isomil Advance
A23 26-32 oz ready to feed Isomil Advance
A20 Alternative Package
104-8 oz ready to feed Isomil Advance

Isomil Advance VC Voucher Message 125 Formula 5-12.9 oz cans powder Isomil
Advance N02 Formula 4-12.9 oz cans powder Isomil
Advance 104 Formula 15-13 oz cans concentrate
Isomil Advance 115 Formula 16-13 oz cans concentrate
Isomil Advance 123 Formula 13-32 oz containers ready to feed
Isomil Advance 123 Formula 13-32 oz containers ready to feed
Isomil Advance N42 Formula 24-8 oz containers ready to feed
Isomil Advance N42 Formula 24-8 oz containers ready to feed
Isomil Advance N42 Formula 24-8 oz containers ready to feed
Isomil Advance N42 Formula 24-8 oz containers ready to feed
Isomil Advance N43 Formula 8-8 oz containers ready to feed
Isomil Advance

FP-56

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Similac Sensitive

Food Package Code

VC Voucher Message

A31

353 Formula 5-12.9 oz cans powder Similac

9-12.9 oz powder

Sensitive

Similac Sensitive

N03 Formula 4-12.9 oz cans powder Similac

Sensitive

Medical Documentation

Required

A32

364 Formula 15-13 oz cans concentrate

31-13 oz concentrate

Similac Sensitive

Similac Sensitive

365 Formula 16-13 oz cans concentrate

Similac Sensitive

Medical Documentation

Required

A33

103 Formula 13-32 oz containers ready to feed

26-32 oz ready to feed

Similac Sensitive

Similac Sensitive

103 Formula 13-32 oz containers ready to feed

Similac Sensitive

Medical Documentation

Required

FP-57

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Food Package Code A41 9-12.9 oz powder Similac Sensitive RS
Medical Documentation Required A43 26-32 oz ready to feed Similac Sensitive RS
Medical Documentation Required

Similac Sensitive RS VC Voucher Message N60 Formula 5-12.9 oz cans powder
Similac Sensitive RS
N61 Formula 4-12.9 oz cans powder Similac Sensitive RS
137 Formula 13-32 oz containers ready to feed Similac Sensitive RS
137 Formula 13-32 oz containers ready to feed Similac Sensitive RS

FP-58

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Contract Formulas

Infant Fully formula Fed

4-5 months

Similac Advance EarlyShield

Food Package Code

VC Voucher Message

B11 (Assign A11)

895 Formula 5-12.9 oz cans powder Similac

1012.9 oz powder

Advance EarlyShield

Similac Advance

895 Formula 5-12.9 oz cans powder Similac

EarlyShield

Advance EarlyShield

B12 (Assign A12)

251 Formula 15-13 oz cans concentrate

3413 oz concentrate

Similac Advance EarlyShield

Similac Advance

253 Formula 19-13 oz cans concentrate

EarlyShield

Similac Advance EarlyShield

B13 (Assign A13)

114 Formula 14-32 oz containers ready to feed

2832 oz ready to feed

Similac Advance EarlyShield

Similac Advance

114 Formula 14-32 oz containers ready to feed

EarlyShield

Similac Advance EarlyShield

B10 (Assign A10)

N58 Formula 24-8 oz containers ready to feed

Alternative package

Similac Advance EarlyShield

112-8 oz ready to feed Similac Advance EarlyShield

N58 Formula 24-8 oz containers ready to feed Similac Advance EarlyShield
N58 Formula 24-8 oz containers ready to feed Similac Advance EarlyShield

N58 Formula 24-8 oz containers ready to feed

Similac Advance EarlyShield

N54 Formula 16-8 oz containers ready to feed

Similac Advance EarlyShield

FP-59

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Isomil Advance

Food Package Code

VC Voucher Message

B21 (Assign A21)

125 Formula 5-12.9 oz cans powder Isomil

1012.9 oz powder Isomil

Advance

Advance

125 Formula 5-12.9 oz cans powder Isomil

Advance

B22 (Assign A22)

104 Formula 15-13 oz cans concentrate

34-13 oz concentrate

Isomil Advance

Isomil Advance

119 Formula 19-13 oz cans concentrate

Isomil Advance

B23 (Assign A23)

124 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Isomil Advance

Isomil Advance

124 Formula 14-32 oz containers ready to feed

Isomil Advance

B20 (Assign A20)

N42 Formula 24-8 oz containers ready to feed

Alternative Package

Isomil Advance

112-8 oz ready to feed Isomil Advance

N42 Formula 24-8 oz containers ready to feed Isomil Advance
N42 Formula 24-8 oz r containers ready to feed

Isomil Advance

N42 Formula 24-8 oz containers ready to feed

Isomil Advance

N56 Formula 16-8 oz containers ready to feed

Isomil Advance

FP-60

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Similac Sensitive

Food Package Code

VC Voucher Message

B31 (Assign A31)

353 Formula 5-12.9 oz cans powder Similac

10-12.9 oz powder

Sensitive

Similac Sensitive

353 Formula 5-12.9 oz cans powder Similac

Sensitive

Medical Documentation

Required

B32 (Assign A32)

364 Formula 15-13 oz cans concentrate

34-13 oz concentrate

Similac Sensitive

Similac Sensitive

386 Formula 19-13 oz cans concentrate

Similac Sensitive

Medical Documentation

Required

B33 (Assign A33)

132 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Similac Sensitive

Similac Sensitive

132 Formula 14-32 oz containers ready to feed

Similac Sensitive

Medical Documentation

Required

FP-61

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Similac Sensitive RS Food Package Code B41 (Assign A41) 10-12.9 oz powder Similac Sensitive RS

VC Voucher Message N60 Formula 5-12.9 oz cans powder
Similac Sensitive RS

N60 Formula 5-12.9 oz cans powder

Medical Documentation

Similac Sensitive RS

Required

B43 (Assign A43) 28-32 oz ready to feed Similac Sensitive RS

139 Formula 14-32 oz containers ready to feed Similac Sensitive RS
139 Formula 14-32 oz containers ready to feed Similac Sensitive RS

Medical Documentation Required

FP-62

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Contract Formulas Infant Fully formula Fed
6- 11 months

Similac Advance EarlyShield

Food Package Code

VC

D11 (Assign A11)

N59

7-12.9 oz powder Similac

Advance EarlyShield

894

32-4 oz infant food

N26

3-8 oz cereal N01

Voucher Message Formula 4-12.9 oz cans powder Similac
Advance EarlyShield Formula 3-12.9 oz cans powder Similac
Advance EarlyShield Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd
foods single ingredient only) Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd
foods single ingredient only)

D12 (Assign A12) 24-13 oz concentrate Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal

Infant 3-8 oz containers cereal: N25 Formula 12-13 oz cans concentrate
Similac Advance EarlyShield N25 Formula 12-13 oz cans concentrate
Similac Advance EarlyShield N26 Infant 16-4 oz containers baby food fruit
foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)

D13 (Assign A13) 20-32 oz ready to feed Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal

Infant cereal: 3-8 oz containers N04 Formula 10-32 oz containers ready to feed
Similac Advance EarlyShield
N04 Formula 10-32 oz containers ready to feed Similac Advance EarlyShield
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)

FP-63

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Food Package Code
D10 (Assign A10) Alternative Package 80-8 oz ready to feed Similac Advance EarlyShield 32-4 oz infant food 3-8 oz cereal

VC Voucher Message N01 Infant 16-4 oz containers baby food fruit
foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
Infant cereal: 3-8 oz containers
N58 Formula 24-8 oz containers ready to feed Similac Advance EarlyShield
N58 Formula 24-8 oz containers ready to feed Similac Advance EarlyShield
N58 Formula 24-8 oz containers ready to feed Similac Advance EarlyShield
N53 Formula 8-8 oz containers ready to feed Similac Advance EarlyShield
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
Infant cereal: 3-8 oz containers

FP-64

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Isomil Advance Food Package Code D21 (Assign A21) 7-12.9 oz powder Isomil Advance 32-4 oz infant food 3-8 oz cereal
D22 (Assign A22) 24-13 oz concentrate Isomil Advance 32-4 oz infant food 3-8 oz cereal
D23 (Assign A23) 20-32 oz ready to feed Isomil Advance 32-4 oz infant food 3-8 oz cereal

VC Voucher Message N02 Formula 4-12.9 oz cans powder Isomil
Advance 135 Formula 3-12.9 oz cans powder Isomil
Advance N26 Infant 16-4 oz containers baby food fruit
foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N06 Formula 12-13 oz cans concentrate Isomil Advance
N06 Formula 12-13 oz cans concentrate Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N07 Formula 10-32 oz containers ready to feed Isomil Advance
N07 Formula 10-32 oz containers ready to feed Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers

FP-65

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Food Package Code D20 (Assign A20) Alternative Package
80-8 oz ready to feed Isomil Advance
32-4 oz infant food
3-8 oz cereal

VC Voucher Message N42 Formula 24-8 oz containers ready to feed
Isomil Advance N42 Formula 24-8 oz containers ready to feed
Isomil Advance N42 Formula 24-8 oz containers ready to feed
Isomil Advance N43 Formula 8-8 oz containers ready to feed
Isomil Advance N26 Infant 16-4 oz containers baby food fruit
foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
Infant cereal: 3-8 oz containers

FP-66

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Similac Sensitive

Food Package Code

VC Voucher Message

D31 (Assign A31)

N03 Formula 4-12.9 oz cans powder Similac

7-12.9 oz powder

Sensitive

Similac Sensitive

N09 Formula 3-12.9 oz cans powder Similac

Sensitive

32-4 oz infant food

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

3-8 oz cereal

foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

D32 (Assign A32)

371 Formula 12-13 oz cans concentrate

24-13 oz concentrate

Similac Sensitive

Similac Sensitive

371 Formula 12-13 oz cans concentrate

Similac Sensitive

32-4 oz infant food

N26 Infant 16-4 oz containers baby food fruit

3-8 oz cereal

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

D33 (Assign A33)

N10 Formula 10-32 oz containers ready to feed

20-32 oz ready to feed

Similac Sensitive

Similac Sensitive

N10 Formula 10-32 oz containers ready to feed

Similac Sensitive

32-4 oz infant food

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

3-8 oz cereal

foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-67

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Food Package Code D41 (Assign A41) 7-12.9 oz powder Similac Sensitive RS
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

Similac Sensitive RS VC Voucher Message N61 Formula 4-12.9 oz cans powder
Similac Sensitive RS

N62 Formula 3-12.9 oz cans powder Similac Sensitive RS

N26 Infant foods:
N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

D43 (Assign A43)

N11 Formula 10-32 oz containers ready to feed

20-32 oz ready to feed

Similac Sensitive RS

Similac Sensitive RS

N11 Formula 10-32 oz containers ready to feed

Similac Sensitive RS

32-4 oz infant food

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

3-8 oz cereal

foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-68

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

Similac Go and Grow EarlyShield Milk-Based (9-12 months only)

Food Package Code

VC Voucher Message

D61 (Assign D61)

N12 Formula 2-22 oz cans powder

4-22 oz powder Similac

Similac Go and Grow EarlyShield

Go and Grow

Milk-Based

EarlyShield Milk-Based N12 Formula 2-22 oz cans powder

Similac Go and Grow EarlyShield

32-4 oz infant food

Milk-Based

N26 Infant 16-4 oz containers baby food fruit

3-8 oz cereal

foods: and/or vegetable (Stage 2 or 2nd

Medical Documentation N01 Infant

Required

foods:

foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

cereal: 3-8 oz containers

Similac Go and Grow Soy-Based (9-12 months only)

Food Package Code

VC Voucher Message

D71 (Assign D71)

N28 Formula 2-22 oz cans powder

4-22 oz powder Similac

Similac Go and Grow Soy-Based

Go and Grow Soy-Based N28 Formula 2-22 oz cans powder

Similac Go and Grow Soy-Based

32-4 oz infant food

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

3-8 oz cereal

foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-69

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-3

Food Package Code E00 Breastfeeding message
E01 (Assign E00) Breastfeeding message 64-4 oz infant food 3-8 oz cereal 31-2.5 oz infant meat

Exclusively Breastfed Infant

VC Voucher Message

059 Message Nurse your baby often. The more you

only

breastfeed the more milk you will

have for your baby.

This does voucher has no cash value

Grocers should not accept this

voucher

059 Message Nurse your baby often. The more you

only

breastfeed the more milk you will

have for your baby

N26 Infant foods:
N26 Infant foods:
N26 Infant foods:
N01 Infant foods:
Infant cereal: N52 Infant foods:

Grocers do not accept this voucher 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 31-2.5 oz containers baby food meat (Stage 1 or 2nd foods only)

FP-70

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant Similac Advance EarlyShield 1- 3 cans per month

Food Package Code E11 1-12.9 oz powder Similac Advance EarlyShield L11 (Assign E11) 1-12.9 oz powder Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal
K11 2-12.9 oz powder Similac Advance EarlyShield M11 (Assign K11) 2-12.9 oz powder Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal
J11 3-12.9 oz powder Similac Advance EarlyShield

VC Voucher Message 874 Formula 1-12.9 oz can powder Similac
Advance EarlyShield
874 Formula 1-12.9 oz can powder Similac Advance EarlyShield
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N16 Formula 2-12.9 oz cans powder Similac Advance EarlyShield
N16 Formula 2-12.9 oz cans powder Similac Advance EarlyShield
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N26 Formula 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
894 Formula 3-12.9 oz cans powder Similac Advance EarlyShield

N11 (Assign J11) 3-12.9 oz powder

894 Formula 3-12.9 oz cans powder Similac Advance EarlyShield
FP-71

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal

N01 Infant foods:
Infant cereal: N26 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

FP-72

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant Similac Advance EarlyShield - Maximum
1-3 months

Food Package Code F11 4-12.9 oz powder Similac Advance EarlyShield F12 14-13 oz concentrate Similac Advance EarlyShield F13 12-32 oz ready to feed Similac Advance EarlyShield

VC Voucher Message N59 Formula 4-12.9 oz cans powder Similac
Advance EarlyShield
N14 Formula 14-13 oz cans concentrate Similac Advance EarlyShield
011 Formula 12-32 oz containers ready to feed Similac Advance EarlyShield

4-5 months - Maximum

Food Package Code G11 (Assign F11) 5-12.9 oz powder Similac Advance EarlyShield G12 (Assign F12) 17-13 oz concentrate Similac Advance EarlyShield G13 (Assign F13) 14-32 oz ready to feed Similac advance EarlyShield

VC Voucher Message 895 Formula 5-12.9 oz cans powder Similac
Advance EarlyShield
N15 Formula 17-13 oz cans concentrate Similac Advance EarlyShield
114 Formula 14-32 oz containers ready to feed Similac Advance EarlyShield

FP-73

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Food Package Code H11 (Assign F11) 4-12.9 oz powder Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal
H12 (Assign F12) 12-13 oz concentrate Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal
H13 (Assign F13) 10-32 oz ready to feed Similac Advance EarlyShield
32-4 oz infant food
3-8 oz cereal

6-11 months - Maximum
VC Voucher Message N59 Formula 4-12.9 oz cans powder Similac
Advance EarlyShield N26 Infant 16-4 oz containers baby food fruit
foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N25 Formula 12-13 oz cans concentrate Similac Advance EarlyShield
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N04 Formula 10-32 oz containers ready to feed Similac Advance EarlyShield
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers

FP-74

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Food Package Code E21 1-12.9 oz powder Isomil Advance L21 (Assign E21) 1-12.9 oz powder Isomil Advance
32-4 oz infant food
3-8 oz cereal
K21 2-12.9 oz powder Isomil Advance M21 (Assign K21) 2-12.9 oz powder Isomil Advance
32-4 oz infant food
3-8 oz cereal
J21 3-12.9 oz powder Isomil Advance N21 (Assign J21) 3-12.9 oz powder Isomil Advance
32-4 oz infant food
3-8 oz cereal

Mostly Breastfed Infant Isomil Advance 1- 3 cans per month
VC Voucher Message 134 Formula 1-12.9 oz can powder Isomil Advance
134 Formula 1-12.9 oz can powder Isomil Advance N26 Infant 16-4 oz containers baby food fruit
foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N19 Formula 2-12.9 oz cans powder Isomil Advance
N19 Formula 2-12.9 oz cans powder Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
135 Formula 3-12.9 oz cans powder Isomil Advance
135 Formula 3-12.9 oz cans powder Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers

FP-75

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Isomil Advance 1-3 months - Maximum

Food Package Code F21 4-12.9 oz powder Isomil Advance F22 14-13 oz concentrate Isomil Advance F23 12-32 oz ready to feed Isomil Advance

VC Voucher Message
N02 Formula 4-12.9 oz cans powder Isomil Advance
N17 Formula 14-13 oz cans concentrate Isomil Advance
122 Formula 12-32 oz containers ready to feed Isomil Advance

Mostly Breastfed Infant / Isomil Advance 4-5 months - Maximum

Food Package Code G21 (Assign F21) 5-12.9 oz powder Isomil Advance G22 (Assign F22) 17-13 oz concentrate Isomil Advance G23 (Assign F23) 14-32 oz ready to feed Isomil Advance

VC Voucher Message 125 Formula 5-12.9 oz cans powder
Isomil Advance
N18 Formula 17-13 oz cans concentrate Isomil Advance
124 Formula 14-32 oz containers ready to feed Isomil Advance

FP-76

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Isomil Advance 6-11months - Maximum

Food Package Code H21 (Assign F21) 4-12.9 oz powder Isomil Advance 32-4 oz infant food 3-8 oz cereal
H22 (Assign F22) 12-13 oz concentrate Isomil Advance 32-4 oz infant food 3-8 oz cereal
H23 (Assign F23) 10-32 oz ready to feed Isomil Advance 32-4 oz infant food 3-8 oz cereal

VC Voucher Message
N02 Formula 4-12.9 oz cans powder Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N06 Formula 12-13 oz cans concentrate Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers
N07 Formula 10-32 oz containers ready to feed Isomil Advance
N26 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only)
N01 Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers

FP-77

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant Similac Sensitive 1- 3 cans per month

Food Package Code

VC Voucher Message

E31

374 Formula 1-12.9 oz can powder Similac

1-12.9 oz powder Similac

Sensitive

Sensitive

Medical Documentation

Required

L31 (Assign E31)

374 Formula 1-12.9 oz can powder Similac

1-12.9 oz powder Similac

Sensitive

Sensitive

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

3-8 oz cereal

N01 Infant 16-4 oz containers baby food fruit

Medical Documentation Required

foods: Infant

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

cereal: 3-8 oz containers

K31

N23 Formula 2-12.9 oz cans powder Similac

2-12.9 oz powder Similac

Sensitive

Sensitive

Medical Documentation

Required

M31 (Assign K31)

N23 Formula 2-12.9 oz cans powder Similac

2-12.9 oz powder Similac

Sensitive

Sensitive

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

32-4 oz infant food

foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

J31

N24 Formula 3-12.9 oz cans powder Similac

3-12.9 oz powder Similac

Sensitive

Sensitive

Medical Documentation Required

FP-78

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Food Package Code

VC Voucher Message

N31 (Assign J31)

N24 Formula 3-12.9 oz cans powder Similac

3-12.9 oz powder Similac

Sensitive

Sensitive

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

32-4 oz infant food

foods single ingredient only)

N01 Infant 16-4 oz containers baby food fruit

3-8 oz cereal

foods: and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

FP-79

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant Similac Sensitive RS 1- 3 cans per month

Food Package Code

VC Voucher Message

E41

111 Formula 1-12.9 oz can powder

1-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

Medical Documentation

Required

L41 (Assign E41)

111 Formula 1-12.9 oz can powder

1-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

3-8 oz cereal

N01 Infant 16-4 oz containers baby food fruit

Medical Documentation Required

foods: Infant

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

cereal: 3-8 oz containers

K41

N64 Formula 2-12.9 oz cans powder

2-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

Medical Documentation

Required

M41 (Assign K41)

N64 Formula 2-12.9 oz cans powder

2-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

32-4 oz infant food

foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

J41

N65 Formula 3-12.9 oz cans powder

3-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

Medical Documentation Required

FP-80

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Food Package Code

VC Voucher Message

N41 (Assign J41)

N65 Formula 3-12.9 oz cans powder

3-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

32-4 oz infant food

foods single ingredient only)

N01 Infant 16-4 oz containers baby food fruit

3-8 oz cereal

foods: and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

FP-81

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Similac Sensitive 1-3 months - Maximum

Food Package Code

VC Voucher Message

F31

N03 Formula 4-12.9 oz cans powder Similac

4-12.9 oz powder Similac

Sensitive

Sensitive

Medical Documentation

Required

F32

N21 Formula 14-13 oz cans concentrate

14-13 oz concentrate

Similac Sensitive

Similac Sensitive

Medical Documentation

Required

F33

102 Formula 12-32 oz containers ready to feed

12-32 oz ready to feed

Similac Sensitive

Similac Sensitive

Medical Documentation Required

FP-82

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Similac Sensitive 4-5 months - Maximum

Food Package Code

VC Voucher Message

G31 (Assign F31)

353 Formula 5-12.9 oz cans powder Similac

5-12.9 oz powder Similac

Sensitive

Sensitive

Medical Documentation

Required

G32 (Assign F32)

N22 Formula 17-13 oz cans concentrate Similac

17-13 oz concentrate

Sensitive

Similac Sensitive

Medical Documentation

Required

G33 (Assign F33)

132 Formula 14-32 oz containers ready to feed

14-32 oz ready to feed

Similac Sensitive

Similac Sensitive

Medical Documentation Required

FP-83

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Similac Sensitive 6-11 months - Maximum

Food Package Code

VC Voucher Message

H31 (Assign F31)

N03 Formula 4-12.9 oz cans powder Similac

4-12.9 oz powder Similac

Sensitive

Sensitive

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

H32 (Assign F32)

371 Formula 12-13 oz cans concentrate

12-13 oz concentrate

Similac Sensitive

Similac Sensitive

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

H33 (Assign F33)

N10 Formula 10-32 oz containers ready to feed

10-32 oz ready to feed

Similac Sensitive

Similac Sensitive

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

FP-84

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Similac Sensitive RS 1-3 months - Maximum

Food Package Code

VC Voucher Message

F41

N61 Formula 4-12.9 oz cans powder

4-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

Medical Documentation

Required

F43

136 Formula 12-32 oz containers ready to feed

12-32 oz ready to feed

Similac Sensitive RS.

Similac Sensitive RS

Medical Documentation Required

Mostly Breastfed Infant / Similac Sensitive RS 4-5 months - Maximum

Food Package Code

VC Voucher Message

G41 (Assign F41)

N60 Formula 5-12.9 oz cans powder

5-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

Medical Documentation

Required

G43 (Assign F43)

139 Formula 14-32 oz containers ready to feed

14-32 oz ready to feed

Similac Sensitive RS

Similac Sensitive RS

Medical Documentation Required

FP-85

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant / Similac Sensitive RS 6-11 months - Maximum

Food Package Code

VC Voucher Message

H41 (Assign F41)

N61 Formula 4-12.9 oz cans powder

4-12.9 oz powder Similac

Similac Sensitive RS

Sensitive RS

N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

32-4 oz infant food

foods single ingredient only)

N01 Infant 16-4 oz containers baby food fruit

3-8 oz cereal

foods: and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

H43 (Assign F43)

N11 Formula 10-32 oz containers ready to feed

10-32 oz ready to feed

Similac Sensitive RS

Similac Sensitive RS

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant cereal:

foods single ingredient only) 3-8 oz containers

FP-86

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-4

Mostly Breastfed Infant Similac Go and Grow EarlyShield Milk-Based - Maximum
9-12 month only

Food Package Code

VC Voucher Message

F61

N12 Formula 2-22 oz cans powder Similac Go &

2-22 oz powder Similac

Grow EarlyShield Milk-Based

Go & Grow EarlyShield N26 Infant 16-4 oz containers baby food fruit

Milk-Based

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

32-4 oz infant food

N01 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

3-8 oz cereal

foods single ingredient only)

Infant

Medical Documentation Required

cereal: 3-8 oz containers

Similac Go and Grow Soy - Maximum 9-12 month olds only

Food Package Code

VC Voucher Message

F71

N28 Formula 2-22 oz cans powder Similac Go &

2-22 oz powder Similac

Grow Soy-Based

Go & Grow Soy-Based N26 Infant 16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

32-4 oz infant food

foods single ingredient only)

3-8 oz cereal

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Medical Documentation Required

Infant cereal: 3-8 oz containers

FP-87

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5

Non-Contract Formulas Infant Fully Formula Fed
0 3 months

Enfamil ProSobee LIPIL or Enfamil Soy LIPIL

Food Package Code

VC Voucher Message

A24

824 Formula 4-12.9 oz cans powder Enfamil

9-12.9 oz powder Enfamil

ProSobee LIPIL or Enfamil Soy LIPIL

ProSobee LIPIL or

825 Formula 5-12.9 oz cans powder Enfamil

Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

Medical Documentation

Required

A25

804 Formula 15-13 oz cans concentrate

31-13 oz concentrate

Enfamil ProSobee LIPIL or Enfamil

Enfamil ProSobee LIPIL

Soy LIPIL

or Enfamil Soy LIPIL

805 Formula 16-13 oz cans concentrate

Enfamil ProSobee LIPIL or Enfamil

Medical Documentation

Soy LIPIL

Required

A26

823 Formula 13-32 oz containers ready to feed

26-32 oz ready to feed

Enfamil ProSobee LIPIL or Enfamil

Enfamil ProSobee LIPIL

Soy LIPIL

or Enfamil Soy LIPIL

823 Formula 13-32 oz containers ready to feed

Enfamil ProSobee LIPIL or Enfamil

Medical Documentation Required

Soy LIPIL

FP-88

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Enfamil AR LIPIL

Food Package Code

VC Voucher Message

A44

N33 Formula 4-12.9 oz cans powder Enfamil AR

9-12.9 oz powder Enfamil

LIPIL

AR LIPIL

168 Formula 5-12.9 oz cans powder Enfamil AR

LIPIL

Medical Documentation

Required

A46

169 Formula 13-32 oz containers ready to feed

26-32 oz ready to feed

Enfamil AR LIPIL

Enfamil AR LIPIL

169 Formula 13-32 oz containers ready to feed

Enfamil AR LIPIL

Medical Documentation

Required

FP-89

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Food Package Code A27 9-12.9 oz powder Nestle Good Start Soy PLUS
Medical Documentation Required A28 31-13 oz concentrate Nestle Good Start Soy PLUS

Nestle Good Start Soy PLUS VC Voucher Message N40 Formula 4-12.9 oz cans powder Nestle Good
Start Soy PLUS N41 Formula 5-12.9 oz cans powder Nestle Good
Start Soy PLUS
N36 Formula 15-13 oz cans concentrate Nestle Good Start Soy PLUS
N37 Formula 16-13 oz cans concentrate Nestle Good Start Soy PLUS

Medical Documentation

Required

A29

N44 Formula 13-32 oz containers ready to feed

26-32 oz ready to feed

Nestle Good Start Soy PLUS

Nestle Good Start Soy

N44 Formula 13-32 oz containers ready to feed

PLUS

Nestle Good Start Soy PLUS

Medical Documentation Required

FP-90

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Non-Contract Formulas Infant Fully formula Fed
4-5 months

Enfamil ProSobee LIPIL or Enfamil Soy LIPIL

Food Package Code

VC Voucher Message

B24 (Assign A24)

825 Formula 5-12.9 oz cans powder Enfamil

10-12.9 oz powder

ProSobee LIPIL or Enfamil Soy LIPIL

Enfamil ProSobee LIPIL 825 Formula 5-12.9 oz cans powder Enfamil

or Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

Medical Documentation

Required

B25 (Assign A25)

804 Formula 15-13 oz cans concentrate Enfamil

34-13 oz concentrate

ProSobee LPIL or Enfamil Soy LIPIL

Enfamil ProSobee LIPIL N30 Formula 19-13 oz cans concentrate Enfamil

or Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

Medical Documentation

Required

B26 (Assign A26)

834 Formula 14-13 oz containers ready to feed

28-32 oz ready to feed

Enfamil ProSobee LIPIL or Enfamil

Enfamil ProSobee LIPIL

Soy LIPIL

or Enfamil Soy LIPIL

834 Formula 14-13 oz containers ready to feed

Enfamil ProSobee LIPIL or Enfamil

Medical Documentation Required

Soy LIPIL

FP-91

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Enfamil AR LIPIL

Food Package Code

VC Voucher Message

B44 (Assign A44)

168 Formula 5-12.9 oz cans powder Enfamil AR

10-12.9 oz Enfamil AR

LIPIL

LIPIL

168 Formula 5-12.9 oz cans powder Enfamil AR

LIPIL

Medical Documentation

Required

B46 (Assign A46)

309 Formula 14-32 oz containers ready to feed

28 32 oz ready to feed

Enfamil AR LIPIL

Enfamil AR LIPIL

309 Formula 14-32 oz containers ready to feed

Enfamil AR LIPIL

Medical Documentation

Required

FP-92

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Nestle Good Start Soy PLUS

Food Package Code

VC

B27 (Assign A27)

N41

10-12.9 oz powder Nestle

Good Start Soy PLUS

N41

Medical Documentation

Required

B28 (Assign A28)

N36

34-13 oz concentrate

Nestle Good Start Soy

N38

PLUS

Voucher Message Formula 5-12.9 oz cans powder Nestle Good
Start Soy PLUS Formula 5-12.9 oz cans powder Nestle Good
Start Soy PLUS

Formula Formula

15-13 oz cans concentrate Nestle Good Start Soy PLUS 19-13 oz cans concentrate Nestle Good Start Soy PLUS

Medical Documentation

Required

B29 (Assign A29)

N45 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Nestle Good Start Soy PLUS

Nestle Good Start Soy

N45 Formula 14-32 oz containers ready to feed

PLUS

Nestle Good Start Soy PLUS

Medical Documentation Required

FP-93

GA WIC 2010 PROCEDURES MANUAL
Non-Contract Formulas Infant Fully formula Fed
6-11 months

Attachment FP-5 (cont'd)

Food Package Code

VC Voucher Message

D24 (Assign A24)

824 Formula 4-12.9 oz cans powder Enfamil

7-12.9 oz Enfamil

ProSobee LIPIL or Enfamil Soy LIPIL

ProSobee LIPIL or

815 Formula 3-12.9 oz cans powder Enfamil

Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

N26 Infant 16-4 oz containers baby food fruit

32-4 oz infant food

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

3-8 oz cereal

N01 Infant 16-4 oz containers baby food fruit

Medical Documentation Required

foods: Infant

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

cereal: 3-8 oz containers

D25 (Assign A25)

N31 Formula 12-13 oz cans concentrate Enfamil

24-13 oz concentrate

ProSobee LIPIL or Enfamil Soy LIPIL

Enfamil ProSobee LIPIL N31 Formula 12-13 oz cans concentrate Enfamil

or Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

32-4 oz infant food

N01 Infant

foods:

3-8 oz cereal

Infant

Medical Documentation

cereal:

Required

N26 Infant

foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

FP-94

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Food Package Code

VC

D26 (Assign A26)

N32

20-32 oz ready to feed

Enfamil ProSobee LIPIL

or Enfamil Soy LIPIL

N32

32-4 oz infant food
N01 3-8 oz cereal

Medical Documentation Required
N26

D74 (Assign D74)

N48

4-24 oz powder Enfagrow Soy

N48

N26

(9-12 months only)

32 jars baby

N01

fruit/vegetable

3-8 oz infant cereal

Medical Documentation

Required

D44 (Assign A44)

N33

7-12.9 oz Enfamil AR

LIPIL

N34

32 jars baby

N01

fruit/vegetable

3-8 oz box infant cereal

Voucher Message Formula 10-32 oz containers ready to feed
Enfamil ProSobee LIPIL or Enfamil Soy LIPIL Formula 10-32oz containers ready to feed Enfamil ProSobee LIPIL or Enfamil Soy LIPIL Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Infant cereal: 3-8 oz containers Infant 16-4 oz containers baby food fruit foods: and/or vegetable (Stage 2 or 2nd foods single ingredient only) Formula 2-24 oz cans powder Enfagrow Soy

Formula 2-24 oz cans powder Enfagrow Soy

Infant foods:
Infant foods:
Infant cereal:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

Formula
Formula
Infant foods:
Infant cereal:

4-12.9 oz cans powder Enfamil AR LIPIL 3-12.9 oz cans powder Enfamil AR LIPIL 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-95

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Food Package Code

VC Voucher Message

Medical Documentation N26 Infant 16-4 oz containers baby food fruit

Required

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

D46 (Assign A46)

N35 Formula 10-32 oz containers ready to feed

2032 oz ready to feed

Enfamil AR LIPIL

Enfamil AR LIPIL

N35 Formula 10-32 oz containers ready to feed

Enfamil AR LIPIL

32 jars baby fruit/vegetable

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

3-8 oz box infant cereal

Infant

cereal: 3-8 oz containers

Medical Documentation N26 Infant

Required

foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

D27 (Assign A27)

N40 Formula 4-12.9 oz cans powder Nestle Good

7-12.9 oz powder Nestle

Start Soy PLUS

Good Start Soy PLUS

N55 Formula 3-12.9 oz cans powder Nestle Good

Start Soy PLUS

32 jars baby

N01 Infant 16-4 oz containers baby food fruit

fruit/vegetable

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

3-8 oz box infant cereal

Infant

cereal:

Medical Documentation N26 Infant

Required

foods:

3-8 oz containers 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

D28 (Assign A28)

N39 Formula 12-13 oz cans concentrate Nestle

24-13 oz concentrate

Good Start Soy PLUS

Nestle Good Start Soy

N39 Formula 12-13 oz cans concentrate Nestle

PLUS

Good Start Soy PLUS

N01 Infant 16-4 oz containers baby food fruit

32 jars baby fruit/vegetable

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

3-8 oz box infant cereal

cereal: 3-8 oz containers

FP-96

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Food Package Code

VC Voucher Message

N26 Infant 16-4 oz containers baby food fruit

Medical Documentation

foods: and/or vegetable (Stage 2 or 2nd

Required

foods single ingredient only)

D29 (Assign A29)

N46 Formula 10-32 oz containers ready to feed

20-32 oz ready to feed

Nestle Good Start Soy PLUS

Nestle Good Start Soy PLUS

N46 Formula 10-32 oz containers ready to feed Nestle Good Start Soy PLUS

32 jars baby fruit/vegetable

N01 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

3-8 oz box infant cereal

Infant cereal: 3-8 oz containers

N26 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

FP-97

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-6

Contract Formula for Children

Similac Advance EarlyShield

Food Package Code

VC

X11

895

9-12.9 oz powder Similac

Advance EarlyShield

N59

Medical Documentation

Required

X12

253

3513 oz concentrate

Similac Advance

252

EarlyShield

Voucher Message Formula 5-12.9 oz cans powder Similac
Advance EarlyShield Formula 4-12.9 oz cans powder Similac
Advance EarlyShield

Formula Formula

19-13 oz cans concentrate Similac Advance EarlyShield 16-13 oz cans concentrate Similac Advance EarlyShield

Medical Documentation

Required

X13

114

28-32 oz ready to feed

Similac Advance

114

EarlyShield

Formula Formula

14-32 oz containers ready to feed Similac Advance EarlyShield 14-32 oz containers ready to feed Similac Advance EarlyShield

Medical Documentation

Required

N58

X10Alternative Package

108-8 oz ready to feed

N58

Similac Advance

EarlyShield

N58

Medical Documentation N58 Required
N66

Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Similac Advance EarlyShield 24-8 oz containers ready to feed Similac Advance EarlyShield 24-8 oz containers ready to feed Similac Advance EarlyShield 24-8 oz containers ready to feed Similac Advance EarlyShield 12-8 oz containers ready to feed Similac Advance EarlyShield

FP-98

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-6 (cont'd)

Isomil Advance

Food Package Code

VC Voucher Message

X21

125 Formula 5-12.9 oz cans powder Isomil

912.9 oz powder Isomil

Advance

Advance

N02 Formula 4-12.9 oz cans powder Isomil

Advance

Medical Documentation

Required

X22

115 Formula 16-13 oz cans concentrate

35-13 oz concentrate

Isomil Advance

Isomil Advance

119 Formula 19-13 oz cans concentrate

Isomil Advance

Medical Documentation

Required

X23

124 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Isomil Advance

Isomil Advance

124 Formula 14-32 oz containers ready to feed

Isomil Advance

Medical Documentation

Required

Similac Sensitive

Food Package Code

VC Voucher Message

X31

353 Formula 5-12.9 oz cans powder Similac

9-12.9 oz powder

Sensitive

Similac Sensitive

N03 Formula 4-12.9 oz cans powder Similac

Sensitive

Medical Documentation

Required

X32

386 Formula 19-13 oz cans concentrate

35-13 oz concentrate

Similac Sensitive

Similac Sensitive

365 Formula 16-13 oz cans concentrate

Similac Sensitive

Medical Documentation

Required

X33

132 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Similac Sensitive

Similac Sensitive

132 Formula 14-32 oz containers ready to feed

Similac Sensitive

Medical Documentation

Required

Similac Sensitive RS

FP-99

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-6 (cont'd)

Food Package Code

VC Voucher Message

X41

N61 Formula 4-12.9 oz cans powder

9-12.9 oz powder Similac

Similac Sensitive R.S.

Sensitive R.S.

N60 Formula 5-12.9 oz cans powder

Medical Documentation

Similac Sensitive R.S.

Required

X43

139

28-32 oz Similac Sensitive

R.S.

139

Medical Documentation Required

Formula Formula

14-32 oz containers ready to feed Similac Sensitive R.S. 14-32 oz containers ready to feed Similac Sensitive R.S.

Similac Go and Grow EarlyShield Milk-Based

Food Package Code

VC Voucher Message

X61

N12 Formula 2-22 oz cans powder

5-22 oz powder Similac

Similac Go and Grow EarlyShield

Go and Grow

Milk-Based

EarlyShield Milk-Based N13 Formula 3-22 oz cans powder

Similac Go and Grow EarlyShield

Medical Documentation

Milk-Based

Required

Similac Go and Grow Soy-Based

Food Package Code

VC Voucher Message

X71

N28 Formula 2-22 oz cans powder

5-22 oz powder Similac

Similac Go and Grow Soy-Based

Go and Grow Soy-Based N29 Formula 3-22 oz cans powder

Similac Go and Grow Soy-Based

Medical Documentation

Required

FP-100

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-7

Non-Contract Infant Formulas for Children

Enfamil AR LIPIL

Food Package Code

VC Voucher Message

X44

N33 Formula 4-12.9 oz cans powder Enfamil AR

9-12.9 oz powder Enfamil

LIPIL

AR LIPIL

168 Formula 5-12.9 oz cans powder Enfamil AR

LIPIL

Medical Documentation

Required

X46

309 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Enfamil AR LIPIL

Enfamil AR LIPIL

309 Formula 14-32 oz containers ready to feed

Enfamil AR LIPIL

Medical Documentation

Required

Enfamil Enfagrow Soy

Food Package Code

VC

X91

N48

5-24 oz powder Enfagrow N49

Soy

Voucher Message Formula 2-24 oz cans powder Enfagrow Soy Formula 3-24 oz cans powder Enfagrow Soy

Medical Documentation Required

FP-101

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Enfamil ProSobee LIPIL or Enfamil Soy LIPIL

Food Package Code

VC Voucher Message

X24

824 Formula 4-12.9 oz cans powder Enfamil

9-12.9 oz powder Enfamil

ProSobee LIPIL or Enfamil Soy LIPIL

ProSobee LIPIL or

825 Formula 5-12.9 oz cans powder Enfamil

Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

Medical Documentation

Required

X25

N30 Formula 19-13 oz cans concentrate Enfamil

35-13 oz concentrate

ProSobee LIPIL or Enfamil Soy LIPIL

Enfamil ProSobee LIPIL 805 Formula 16-13 oz cans concentrate Enfamil

or Enfamil Soy LIPIL

ProSobee LIPIL or Enfamil Soy LIPIL

Medical Documentation

Required

X26

834 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Enfamil ProSobee LIPIL or Enfamil

Enfamil ProSobee LIPIL

Soy LIPIL

or Enfamil Soy LIPIL

834 Formula 14-32 oz containers ready to feed

Enfamil ProSobee LIPIL or Enfamil

Medical Documentation Required

Soy LIPIL

FP-102

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Nestle Good Start Soy PLUS

Food Package Code

VC

X27

N41

10-12.9 oz powder Nestle

Good Start Soy PLUS

N41

Medical Documentation

Required

X28

N38

35-13 oz concentrate

Nestle Good Start Soy

N37

PLUS

Voucher Message Formula 5-12.9 oz cans powder Nestle Good
Start Soy PLUS Formula 5-12.9 oz cans powder Nestle Good
Start Soy PLUS

Formula Formula

19-13 oz cans concentrate Nestle Good Start Soy PLUS 16-13 oz cans concentrate Nestle Good Start Soy PLUS

Medical Documentation

Required

X29

N45 Formula 14-32 oz containers ready to feed

28-32 oz ready to feed

Nestle Good Start Soy PLUS

Nestle Good Start Soy

N45 Formula 14-32 oz containers ready to feed

PLUS

Nestle Good Start Soy PLUS

Medical Documentation Required

FP-103

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-8

Summary of Food Packages for Women and Children

Women Food Packages:

W01 W02 W03 W04
W05 W06
W07
W08 W09
W10 W11

Prenatal/Mostly Breastfeeding W00 W19
Standard Prenatal/Mostly Breastfeeding Women Lactose Intolerant Prenatal/Mostly Breastfeeding Women Goat Milk for Prenatal/Mostly Breastfeeding Women Extra Cheese for Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION REQUIRED Limited Tofu for Prenatal/Mostly Breastfeeding Women Extra Tofu for Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION NEEDED Whole Milk Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION REQUIRED No Cheese for Prenatal/Mostly Breastfeeding Women No Milk for Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION REQUIRED Prenatal/Mostly Breastfeeding Women Alternative Package Soy Milk for Prenatal/Mostly Breastfeeding Women

Postpartum Non-Breastfeeding/Some Breastfeeding W20 W39, W80

W21 W22 W23 W24
W25 W26
W27
W28 W29
W30 W31 W80

Standard Postpartum Women Lactose Intolerant Postpartum Women Goat Milk for Postpartum Women Extra Cheese for Postpartum Women MEDICAL DOCUMENTATION REQUIRED Limited Tofu for Postpartum Women Extra Tofu for Postpartum Women Extra Tofu MEDICAL DOCUMENTATION REQUIRED Whole Milk for Postpartum Women MEDICAL DOCUMENTATION REQUIRED No Cheese for Postpartum Women No Milk for Postpartum Women MEDICAL DOCUMENTATION REQUIRED Postpartum Women Alternative Package Soy Milk for postpartum women Some Breastfeeding >6 months Postpartum

FP-104

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-8 (cont'd)

Exclusively Breastfeeding Woman Single Infant/Prenatal with Multiples W40 W59

W41 W42 W43 W44 W45 W46
W47
W49
W50 W51

Standard Exclusively Breastfeeding/Prenatal with Multiples Lactose Intolerant Exclusively Breastfeeding/Prenatal with Multiples Goat Milk for Exclusively Breastfeeding/Prenatal with Multiples More Cheese for Exclusively Breastfeeding/Prenatal with Multiples Limited Tofu for Exclusively Breastfeeding/Prenatal with Multiples Extra Tofu for Exclusively Breastfeeding/Prenatal with Multiples
MEDICAL DOCUMENTATION NEEDED Whole Milk for Exclusively Breastfeeding/Prenatal with Multiples MEDICAL DOCUMENTATION REQUIRED No Milk for Exclusively Breastfeeding/Prenatal with Multiples
MEDICAL DOCUMENTAION REQUIRED Exclusively Breastfeeding/Prenatal with Multiples Alternative Package Soy Milk for Exclusively Breastfeeding/Prenatal with Multiples

Exclusively Breastfeeding Multiples W60 W79 (V60 V79)

W61 V61 W62 V62 W63 V63 W65 V65 W69
V69
W71 V71

Standard Exclusively Breastfeeding Multiples Package A Standard Exclusively Breastfeeding Multiples Package B Lactose Intolerant Exclusively Breastfeeding Multiples Package A Lactose Intolerant Exclusively Breastfeeding Multiples Package B Goat Milk for Exclusively Breastfeeding Multiples Package A Goat Milk for Exclusively Breastfeeding Multiples Package B Tofu for Exclusively Breastfeeding Multiples Package A Tofu for Exclusively Breastfeeding Multiples Package B No milk for Exclusively Breastfeeding Multiples Package A MEDICAL DOCUMENTATION REQUIRED No milk for Exclusively Breastfeeding Multiples Package B MEDICAL DOCUMENTATION REQUIRED Soy Milk for Exclusively Breastfeeding Multiples Package A Soy Milk for Exclusively Breastfeeding Multiples Package A

FP-105

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-8 (cont'd)

Child Food Packages:
12 23 Month Old Child C00 C19
C01 Standard Child 1-2 years old C02 Lactose Intolerant 1-2 year old C03 Goat Milk for 1 -2 year old C05 Limited Tofu for 1-2 yr old
MEDICAL DOCUMENTATION REQUIRED C06 Extra Tofu for 1-2 year old
MEDICAL DOCUMENTATION REQUIRED C09 No milk for 1-2 year old
MEDICAL DOCUMENTAION NEEDED C10 1-2 year old Alternative Package C11 Soy Milk for 1-2 years old
MEDICAL DOCUMENTATION REQUIRED
2 - 5 Year Old Child C20 C39
C21 Standard 2-5 year old C22 Lactose Intolerant 2- 5 year old C23 Goat Milk for 2-5 year old C24 Extra Cheese for 2-5 yr old child
MEDICAL DOCUMENTATION REQUIRED C25 Limited Tofu for 2-5 yr child
MEDICAL DOCUMENTATION REQUIRED C26 Extra Tofu for 2-5 yr child
MEDICAL DOCUMENTATION REQUIRED C27 Whole Milk for 2 -5 year old
MEDICAL DOCUMENTATION REQUIRED C28 No Cheese for 2-5 year old C29 No milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED C30 2-5 year old Alternative Package C31 Soy Milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED

FP-106

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9

Women Food Packages Prenatal/Mostly Breastfeeding W00-W19

Food Package Number W01 Standard Prenatal/Mostly Breastfeeding Women
$8 fruit and vegetable
4 gallons of milk
1-3 qt box dry milk
1 lb cheese
3-48 oz cans of juice
1 dozen eggs
36 oz cereal
16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC Voucher Message

P01 Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

041 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

Eggs:

brand

1 dozen

Juice:

2 containers (46 to 48 oz) or 2-12 oz

cans frozen or 2-11.5 oz cans pourable

concentrate

Cereal: No more than 36 oz.

W01 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Dry Milk 1- 3 quart box non-fat dry powder

Cheese: 1-16 oz package

Peanut butter: W02 Milk:

1 container (16 to 18 oz)
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 040 Milk:

1 lb dried or 4 cans (14 to 16 oz) 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-107

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package number W02 Lactose Intolerant Prenatal/Mostly Breastfeeding Women
$8 fruit and vegetable
19 qt lactose reduced milk
1 lb cheese
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC VC Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 034 Milk: 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand Juice: 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 024 Milk: 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Beans: 033 Milk:

1 lb dried or 4 cans (14 to 16 oz) 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: No more than 36 oz

FP-108

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

501 Milk:

1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Juice: W07 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 3 quarts or 1-half gallon low-fat (fatfree, 1%, 2%) Lactose-free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

W80

Cheese: Eggs: Whole grain:

1-16 oz package
1 dozen Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Peanut 1 container (16 to 18 oz) butter:

FP-109

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package W03 Goat Milk for Prenatal/Mostly Breastfeeding Women
$8 fruit and vegetable
19 quarts goat milk
1 lb cheese
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC P01
W11

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed or

diced tomatoes.

Goat

3 quarts low-fat goat milk No whole

milk: Milk.

W12

Cheese: Peanut butter: Goat milk:

1-16 oz package
1 container (16 to 18 oz) 4 quarts low-fat goat milk No whole Milk.

Juice:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate

Whole grain:
W13 Goat milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 4 quarts low-fat goat milk No whole milk.

Beans: W14 Goat
milk:

1 lb dried or 4 cans (14 to 16 oz) 4 quarts low-fat goat milk. No whole milk.

Juice:
Eggs: W15 Goat
milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 4 quarts low-fat goat milk No whole milk.

Cereal: No more than 36 oz

FP-110

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package Number W04 Extra Cheese for Prenatal/Mostly Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
$8 fruit and vegetable
4 gallon milk
2 lb cheese
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried bean

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 041 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand Juice: 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate

Eggs: Cereal: W45 Milk:

1 dozen No more than 36 oz. 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

W02

Cheese: Peanut butter: Milk:

1-16 oz package
1 container (16 to 18 oz) 1gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
Beans: 031 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz)
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: Cheese:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1-16 oz package

FP-111

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package Number W05 Limited Tofu for Prenatal/Mostly Breastfeeding Women
$8 fruit and vegetable
5 gallons of milk
2 lb of tofu
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 041 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: Cereal: W37 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen No more than 36 oz.
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

W02

Cheese: Tofu: Peanut butter: Milk:

Whole Grain:

Beans: 051 Milk:

1-16 oz package 2 pounds
1 container (16 to 18 oz) 1gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-112

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package Number W06 Extra Tofu for Prenatal/Mostly Breastfeeding Women
MEDICAL DOCUMENTATION NEEDED
$8 fruit and vegetable
3 gallon milk
10 lb tofu
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 041 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: Eggs: Cereal: W37 Milk:
Cheese:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen No more than 36 oz.
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1-16 oz package

W38

Tofu: Peanut butter: Tofu:

2 pounds
1 container (16 to 18 oz) 4 pounds

Whole Grain:
Beans: W43 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Tofu: 4 pounds

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-113

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package Number W07 Whole Milk for Prenatal/Mostly Breastfeeding Women
Can only be given with food package III
MEDICAL DOCUMENTATION REQUIRED
$8 fruit and vegetable
5 gallon whole milk
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 046 Milk: 1 gallon Whole milk only Least expensive brand

Juice: C04 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs: W47 Milk:

1 dozen 2 gallons Whole milk only Least expensive brand

Juice: W48 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: W49 Milk:
Peanut butter:

1 lb dried or 4 cans (14 to 16 oz) 1 half gallon whole milk only Least expensive brand
1 container (16 to 18 oz)

FP-114

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package W08 No Cheese for Prenatal/Mostly Breastfeeding Women
$8 fruit and vegetable
5 gallon milk
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 039 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: W02 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen
1gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
Beans:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz)

FP-115

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

040 Milk:

1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: 029 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W20 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1-half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cereal: Peanut Butter:

No more than 36 oz 1 container (16-18 oz)

FP-116

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package W09 No Milk for Prenatal/Mostly Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III
$8 Fruit and vegetable
1 lb cheese
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)

VC P01
W54

Voucher Message Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Cheese: 1-16 oz package

Eggs: 1 dozen

Cereal: W55 Juice:
Whole Grain:
Beans: W56 Juice:
Peanut Butter:

No more than 36 oz 1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate
1 container (16-18 oz)

1 lb dried beans

FP-117

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package Number W10 Prenatal/Mostly Breastfeeding Women Alternative Package
$8 fruit and vegetable
88-8 oz UHT milk
24-6oz cans juice

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. H14 Milk: 12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

36 oz cereal
16 oz whole grains
2 containers of peanut butter (16-18 oz. each)

Juice: H15 Milk:
Juice:

6 cans (5.5 to 6 oz) 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.
6 cans (5.5 to 6 oz)

Peanut butter: H15 Milk:

1 container (16 to 18 oz)
12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice: 6 cans (5.5 to 6 oz)

Peanut butter: H13 Milk:

1 container (16 to 18 oz)
12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: H13 Milk:

No more than 18 oz 12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: H14 Milk:

No more than 18 oz 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Juice: 6 cans (5.5 to 6 oz)

FP-118

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

H01 Milk:
Whole Grain:

16-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.
Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-119

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-9 (cont'd)

Food Package W11 Soy Milk for Prenatal/Mostly Breastfeeding Women
$8 fruit and vegetable
5 gallons soy milk
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

VC P01
W28

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed or

diced tomatoes.

Soy

3 half gallons 8th Continent

Milk: (Original flavor only)

W30

Peanut butter: Soy milk: Juice:

1 container (16 to 18 oz) 2 half gallons 8th Continent (Original flavor only) 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate

Whole grain:
W57 Soy milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 2 half gallons 8th Continent (Original flavor only)

Beans: W69 Soy
milk:

1 lb dried or 4 cans (14 to 16 oz) 2 half gallons 8th Continent (Original flavor only)

Juice:
Eggs: W70 Soy
milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 2 half gallons 8th Continent (Original flavor only)

Cereal: No more than 36 oz

FP-120

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10

Non-Breastfeeding Postpartum Women/Breastfeeding Some W20 - W39

Food Package Number W21 Standard Postpartum/Some Breastfeeding Women
$8 fruit and vegetable
2 gallon milk
1-3 qt box dry milk
2-48 oz juice
1 lb cheese
1 dozen eggs
36 oz cereal

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. W41 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W04 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

1 lb dried beans or 1

Cheese:

container of peanut butter W05 Milk:

(16-18 oz.)

1-16 oz package
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: W06 Dry
milk:

No more than 36 oz. 1- 3 quart non-fat dry powder

Beans/ peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-121

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package

VC Voucher Message

W22 Lactose Intolerant P01 Produce: $8 for fresh, frozen, or canned fruit

Postpartum/Some

and vegetables

Breastfeeding Women

No potatoes-except for sweet

potatoes or yams. No products with

$8 fruit and vegetable

added sugar, seasonings, fat, or oils.

13 quarts of lactose reduced milk

034 Milk:

No creamed vegetables. No stewed or diced tomatoes. 1 gallon or 4 quarts or 2 half gallons

1 lb cheese

low- fat (fat-free, 1%, 2%) Lactose free, Acidophilus, or Acidophilus

2-48 oz juice

and Bifidum. No whole milk. Least expensive brand

1 dozen eggs

Juice:

36 oz cereal
033 1 lb dried bean or 1 container of peanut butter (16-18 oz.)

Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 211.5 oz cans pourable concentrate 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: 045 Milk:

No more than 36 oz 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Beans/ peanut butter:
W10 Milk:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter 1 quart low-fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Cheese: 1-16 oz package Eggs: 1 dozen

FP-122

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package W23 Goat Milk for Postpartum/Some Breastfeeding Women
$8 fruit and vegetable
13 quarts goat milk
1 lb cheese
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC P01
W14

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Goat

4 quarts low-fat goat milk No whole

milk:

milk.

Juice:
Eggs: W15 Goat
milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 4 quarts low-fat goat milk No whole milk.

Cereal: W18 Goat
milk:

No more than 36 oz 4 quarts low-fat goat milk No whole Milk.

Juice:
W19 Goat milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 quart low-fat goat milk. No whole Milk.

Cheese: 1-16 oz package

Beans/ peanut butter

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-123

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package Number W24 Extra Cheese for Postpartum/Some Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
$8 Fruit and vegetable
2 gallon milk
2 lb cheese
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried bean or 1 container of peanut butter (16-18 oz.)

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 040 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W04 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: W05 Milk:

1-16 oz package
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: Cereal: W46 Juice:
Cheese:

1 dozen No more than 36 oz
1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1-16 oz package

Beans/ Peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-124

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package Number W25 Limited Tofu for Postpartum/Some Breastfeeding Women
$8 fruit and vegetable
3 gallon of milk
4 lb tofu
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 040 Milk: 1 gallon only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: 040 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W05 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal W42 Tofu:

No more than 36 oz. 4 pounds

Beans/ Peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-125

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package Number W26 Extra Tofu for Postpartum/Some Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
$8 Fruit and vegetable
2 gallon milk
8 lb tofu
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC Voucher Message P01 Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 040 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W05 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: Cereal W42 Tofu:

1 dozen No more than 36 oz. 4 pounds

W39

Beans or Peanut butter: Tofu:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter 4 pounds

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-126

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package Number W27 Whole Milk for Postpartum/Some Breastfeeding Women
Can only be given with food package III
MEDICAL DOCUMENTATION REQUIRED
$8 fruit and vegetable
4 gallons whole milk
2-48 oz juice
1 dozen eggs
36 oz cereal
1 dried beans or 1 container of peanut butter (16-18 oz.)

VC Voucher Message

P01 Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed

or diced tomatoes.

046 Milk:

1 gallon Whole milk only

Least expensive brand

Juice: C04 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon Whole milk only Least expensive brand

Cereal: Eggs: 046 Milk:

No more than 36 oz 1 dozen
1 gallon Whole milk only Least expensive brand

Juice: W52 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon whole milk only Least expensive brand

Beans/ peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-127

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package W28 No Cheese for Postpartum/Some Breastfeeding Women
$8 fruit and vegetable
4 gallon milk
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC Voucher Message

P01 Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

039 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:
Eggs: 040 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W21 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cereal: W22 Milk:

No more than 36 oz
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Beans/ Peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-128

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package W29 No Milk for Postpartum/Some Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III
$8 fruit and vegetable
1 lb cheese
2-48 oz juice
1 dozen eggs
36 oz cereal

VC P01
W46
W71

Voucher Message Produce: $8 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Cheese: 1-16 oz package

Juice:
Beans/ Peanut butter: Juice:
Eggs:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter 1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen

1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Cereal: No more than 36 oz

FP-129

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package W30 Postpartum/Some Breastfeeding Women Alternative Package
$8 fruit and vegetable
64- 8 oz UHT milk
16-6 oz juice
36 oz cereal
1 container of peanut butter (16-18 oz.)

VC Voucher Message

P01 Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

H15 Milk:

12-8 oz or half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Juice:

6 cans (5.5 to 6 oz)

Peanut butter: H14 Milk:

1 container (16 to 18 oz)
12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice: H13 Milk:

6 cans (5.5 to 6 oz ) 12-84oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: H13 Milk:

Not more than 18 oz 12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: H02 Milk:

Not more than 18 oz 16-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice:

4 cans (5.5 to 6 oz)

FP-130

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Food Package W31 Soy Milk for Postpartum/Some Breastfeeding Women
$8 fruit and vegetable
4 gallons soy milk
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC P01
W69

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit

and vegetables

No potatoes except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Soy

2 half gallons 8th Continent

milk:

(Original flavor only)

Juice:
Eggs: W70 Soy
milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 2 half gallons 8th Continent (Original flavor only)

Cereal: W72 Soy
milk:

No more than 36 oz 2 half gallons 8th Continent (Original flavor only)

Juice:
W73 Soy milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 2 half gallons 8th Continent (Original flavor only)

Beans/ peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

Food Package Number W80 Some Breastfeeding >6 months postpartum and <50% of the time

VC W60

Voucher Message Good Job! Keep breastfeeding to provide your baby with the BEST milk.

FP-131

GA WIC 2009 PROCEDURES MANUAL

Attachment FP-11

Exclusively Breastfeeding Woman Single Infant or Prenatal Woman Pregnant with Multiples W40- W59

Food package Number W41 Standard Exclusively Breastfeeding/Prenatal Women with Multiples Package/MBF Multiples
$10 fruit and vegetable
6 gallons milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

VC P02 W82
039
W02

Voucher message Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Milk: 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand Juice: 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 211.5 oz cans pourable concentrate Eggs: 1 dozen Cereal: No more than 36 oz Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: Milk:

1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen
1gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
Beans: W03 Milk:
Cheese: Peanut Butter: Fish:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1-16 oz package
1 container (16 to 18 oz) No more than 30 oz

FP-132

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package number W42 Lactose Intolerant Exclusively Breastfeeding/ Prenatal women with Multiples/ MBF Multiples
$10 fruit and vegetable
24 qt lactose reduced milk
1 lb cheese

VC VC Message P02 Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 034 Milk: 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

3-48 oz juice 2 dozen eggs 36 oz cereal 16 oz whole grain 1 container of peanut butter (16-18 oz.) 1 lb dried beans 30 oz fish

Juice: 024 Milk:
Beans: 033 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 211.5 oz cans pourable concentrate 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand
1 lb dried or 4 cans (14 to 16 oz) 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: No more than 36 oz

FP-133

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

501 Milk:

1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum. No whole milk. Least expensive brand

Juice:
W09 Milk:
Cheese: Eggs: W08 Eggs: Whole Grain: Peanut butter: Fish:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 2 gallon or 8 quarts or 4 half gallons low- fat (fat-free, 1%, 2%) Lactosefree, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand 1-16 oz package 1 dozen 1 dozen Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 container (16 to 18 oz) No more than 30 ounces

FP-134

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W43 Goat Milk for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples $10 fruit and vegetable
24 quarts goat milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain

VC P02
W12

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed or

diced tomatoes.

Goat

4 quarts low-fat goat milk No whole

Milk: Milk.

Juice: Whole Grain:
W17 Goat Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 6 quarts low-fat goat milk. No whole milk.

1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Beans:
Eggs: W14 Goat
Milk:
Juice:

1 lb dried or 4 cans (14 to 16 oz)
1 dozen 4 quarts low-fat goat milk. No whole milk.
1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Eggs: 1 dozen

FP-135

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

W15 Goat Milk:

4 quarts low-fat goat milk No whole milk.

Cereal W16 Goat
Milk:

No more than 36 oz 6 quarts low-fat goat milk. No whole milk.

Cheese: Peanut Butter: Fish:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz

FP-136

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W44 More cheese for Exclusively Breastfeeding/ Prenatal Women with Multiples/MBF Multiples
$10 Fruit and Vegetable
4 gallon milk
3 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

VC Voucher Message P02 Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 041 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: Cereal: 039 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen No more than 36 oz.
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: W03 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen
2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: Peanut Butter: Fish:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz

FP-137

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

W04 Milk:

1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package W44 Cheese: 1-16 oz package

Whole Grain:
Beans:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz)

FP-138

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W45 Limited Tofu for Exclusively Breastfeeding/ Prenatal Women with Multiples/MBF Multiples
$10 fruit and vegetables
5 gallons milk
1 lb cheese
4 lb tofu
3-48 oz cans juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried Beans
30 oz fish

VC Voucher Message P02 Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. W82 Milk: 2 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: Cereal: 039 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen No more than 36 oz.
1 gallon only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Eggs: W38 Tofu:

1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen
4 pounds

Whole Grain:
Beans W03 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: Peanut Butter: Fish:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz

FP-139

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W46 Extra Tofu for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
3 gallons milk
1 lb cheese
12 lb tofu
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

VC P02
W38

Voucher Message Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Tofu: 4 pounds

Whole Grain:
Beans 039 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 1 gallon only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Juice: 050 Milk:
Juice:

1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Eggs

1 dozen

Cereal: No more than 36 oz

FP-140

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

W39 Tofu: 4 pounds

Juice: W40 Milk:
Cheese:

1-12 oz can frozen or 1-46 oz container or 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1-16 oz package

Peanut Butter: Fish: A11 Tofu:

1 container (16 to 18 oz) No more than 30 oz
4 pounds

FP-141

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W47 Whole Milk for Exclusively breastfeeding/ Prenatal Women with Multiples/MBF Multiples
Can only be given with food package III
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
6 gallons whole milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

VC Voucher Message P02 Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. W51 Milk: 1 gallon Whole milk only Least expensive brand

Juice:
Fish: C04 Milk:

1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate No more than 30 oz
1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs: W47 Milk:

1 dozen 2 gallons Whole milk only Least expensive brand

Juice:
Milk: W48

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 gallon Whole milk only Least expensive brand

Whole Grains:
Beans: W50 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 1 gallon Whole milk only Least expensive brand

Cheese: Eggs: Peanut Butter:

1-16 oz package 1 dozen
1 container (16 to 18 oz)

FP-142

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W49 No milk Exclusively Breastfeeding/ Prenatal with Multiples/ MBF Multiples
MEDICAL DOCUMENTAION REQUIRED Can only be given with food package III
$10 fruit and vegetable
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

VC P02
W44

Voucher Message Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Cheese: 1-16 oz package

Whole Grain:
Beans: W58 Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 1 dozen

Cereal: W59 Juice:
Fish: W61 Juice:

No more than 36 oz 1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate No more than 30 oz 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate

Eggs: 1 dozen

Peanut 1 container (16 to 18 oz) Butter:

FP-143

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W50 Exclusively Breastfeeding/Prenatal with Multiples/MBF Multiples Alternative Package
$10 fruit and vegetable
96-8 oz UHT milk
16 oz cheese
24-6 oz juice
36 oz cereal
16 oz whole grain
2 containers of peanut butter (16-18 oz. each)
8-16 oz cans beans
30 oz fish

VC Voucher Message P02 Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. H14 Milk: 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Juice: H20 Milk:
Cereal:

6 cans (5.5 to 6 oz ) 15-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk. Not more than 18 oz

Juice: Peanut butter: H20 Milk:
Cereal:

6 cans (5.5 to 6 oz)
1 container (16 to 18 oz) 15-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk. Not more than 18 oz

Juice: Peanut butter:

6 cans (5.5 to 6 oz) 1 container (16 to 18 oz)

FP-144

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

H03 Milk:

15-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Cheese: 1-16 oz package

Whole grain:
H04 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 15-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Beans: H14 Milk:

4 cans (14 to 16 oz) 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Juice: H05 Milk:

6 cans (5.5 to 6 oz) 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Beans: 4 cans (14 to16 oz)

Fish:

No more than 30 ounces

FP-145

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

W51 Soy Milk for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples
$10 fruit and vegetable
6 gallons soy milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal

P02 W30 W74

Produce:
Soy Milk: Juice:
Whole Grain: Soy Milk:

$10 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. 2 half gallons 8th Continent (Original flavor only) 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 4 half gallons 8th Continent (Original flavor only)

16 oz whole grain

Eggs: 1 dozen

1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Beans: W69 Soy
Milk:
Juice:
Eggs: W70 Soy
Milk:

1 lb dried or 4 cans (14 to 16 oz) 2 half gallons 8th Continent (Original flavor only)
1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 2 half gallons 8th Continent (Original flavor only)

Cereal W75 Soy
Milk:

No more than 36 oz 2 half gallons 8th Continent (Original flavor only)

Cheese: Peanut Butter: Fish:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz

FP-146

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12

Exclusively Breastfeeding Multiples W60 W79 (V60 V79)

Food Package

VC Voucher Message

W61 Exclusively

P04 Produce: $15 for fresh, frozen, or canned fruit

Breastfeeding Multiples

and vegetables

- Standard Package A

No potatoes-except for sweet potatoes

$15 fruit and vegetable

or yams. No products with added sugar, seasonings, fat, or oils. No

9 gallon milk

creamed vegetables. No stewed or diced tomatoes.

2 lb cheese

W82 Milk:

2 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive

4-48 oz juice

brand

3 dozen eggs

Juice:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable

54 oz cereal

Eggs::

concentrate 1 dozen

16 oz whole grain

Cereal: No more than 36 oz. W03 Milk: 2 gallons low-fat (fat-free, 1%, 2%)

1 container of peanut butter (16-18 oz.)

Cheese:

No whole milk. Least expensive brand 1-16 oz package

2 lb dried beans

Peanut butter: 1 container (16 to 18 oz)

45 oz fish

Fish: 029 Milk:

No more than 30 ounces 2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-147

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

031 Milk: Juice:

1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Cheese: W23 Milk:

1-16 oz package 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: W02 Milk:

No more than 18 oz
1gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
Beans: W24 Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz)
1 dozen

Beans: 1 lb dried or 4 cans (14 to 16 oz)

Fish:

No more than 15 oz

FP-148

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package V61 (Assign W61) Exclusively Breastfeeding Multiples Standard Package B
$15 fruit and vegetables
9 gallons of milk
1 lb cheese

VC P04
W82

Voucher Message Produce: $15 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Milk: 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

5-48 oz juice 3 dozen eggs 54 oz cereal 32 oz whole grains 2 container of peanut butter (16-18 oz. each) 1 lb dried beans 45 oz fish

Juice:
Eggs: Cereal: W03 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen No more than 36 oz
2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

Peanut

Butter: 1 container (16 to 18 oz)

Fish:

No more than 30 oz

029 Milk: 2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-149

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

W23 Milk:

1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: No more than 18 oz W53 Eggs: 1 dozen

Whole Grain:
Fish: W26 Milk:
Juice:
Peanut butter: Beans:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns No more than 15 oz 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate
1 container (16 to 18 oz) 1 lb dried or 4 cans (14 to 16 oz)

FP-150

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W62 Lactose Intolerant Exclusively Breastfeeding Multiples Package A
$15 fruit and vegetables
36 quarts lactose reduced milk
2 lb cheese
4-48 oz cans juice
3 dozen eggs
54 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

VC P04 W27
W09
024

Voucher Message

Produce: $15 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Milk: 2 gallons or 8 quarts or 4 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, or Acidophilus, or Acidophilus

and Bifidum No whole milk. Least

expensive brand

Juice: 2 containers (46 to 48 oz) or 2-12 oz

cans frozen or 2-11.5 oz cans pourable

concentrate

Eggs: 1 dozen

Milk:

2 gallons or 8 quarts or 4 half gallons

low-fat (fat-free, 1%, 2%) Lactose

free, or Acidophilus, or Acidophilus

and Bifidum No whole milk. Least

expensive brand

Cheese: Eggs: Milk:

1-16 oz package 1 dozen
1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-151

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

034 Milk:

1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Juice: 033 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Cereal: W29 Milk:

W08

Cheese: Cereal: Fish: Eggs:

No more than 36 oz
1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand 1-16 oz package No more than 18 oz No more than 15 oz 1 dozen

Whole Grain:
Peanut Butter: Fish: 024 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 container (16-18 oz) No more than 30 ounces 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-152

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package V62 (Assign W62) Lactose Intolerant Exclusively Breastfeeding Multiples Package B
$15 fruits and vegetables
36 quarts lactose reduced milk
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal
32 oz whole grains
2 container of peanut butter (16-18 oz. each)
1 lb dried beans
45 oz fish

VC P04 W27
W09 024

Voucher message Produce: $15 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Milk: 2 gallons or 8 quarts or 4 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand Juice: 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate Eggs: 1 dozen Milk: 2 gallons or 8 quarts or 4 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand Cheese: 1-16 oz package Eggs: 1 dozen Milk: 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-153

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

034 Milk:

1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Juice: 033 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free or Acidophilus and Bifidum No whole milk. Least expensive brand

Cereal: 501 Milk:

No more than 36 oz. 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free or Acidophilus and Bifidum No whole milk. Least expensive brand

Juice: W31 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

W25

Peanut Butter: Fish: Eggs: Cereal:

2- containers (16 to 18 oz) peanut butter No more than 30 oz 1 dozen No more than 18 oz

Whole Grain:
Fish:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns No more than 15 oz

FP-154

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W63 Goat Milk for Exclusively Breastfeeding Multiples Package A
$15 fruits and vegetables
36 quarts of goat milk
2 lb cheese
4-48 oz juice
3 dozen eggs
54 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

VC P04
W17

Voucher message

Produce: $15 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Goat

6 quarts low-fat goat milk. No whole

Milk: milk.

Eggs: 1 dozen

Beans: W16 Goat
Milk:

1 lb dried or 4 cans (14 to 16 oz) 6 quarts low-fat goat milk. No whole milk.

W14

Cheese: Peanut Butter: Fish: Goat Milk:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz 4 quarts low-fat goat milk No whole milk.

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Eggs: 1 dozen

FP-155

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

W32 Goat Milk:

8 quarts low-fat goat milk No whole milk.

Cheese: 1-16 oz package

Juice:
W33 Goat Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 6 quarts low-fat goat milk No whole milk.

Juice:

1-46 oz container or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Cereal: W34 Goat
Milk:

No more than 36 oz 6 quarts low-fat goat milk No whole milk.

Cereal: No more than 18 oz

Whole Grain:
W24 Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 dozen

Beans: 1 lb dried or 4 cans (14 to 16 oz)

Fish:

No more than 15 oz

FP-156

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package V63 (Assign W63) Goat Milk for Exclusively Breastfeeding Multiples Package B
$15 fruits and vegetables
36 qt goat milk
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal
32 oz whole grain
2 containers of peanut butter (16-18 oz. each)
1 lb dried beans
45 oz fish

VC P04
W17 W16
W14

Voucher message

Produce: $15 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Goat

6 quarts low-fat goat milk. No whole

milk: milk.

Eggs: 1 dozen

Beans: Goat milk:

1 lb dried or 4 cans (14 to 16 oz) 6 quarts low-fat goat milk No whole milk.

Cheese: Peanut butter: Fish: Goat milk:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz 4 quarts low-fat goat milk. No whole milk.

Juice: Eggs:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen

FP-157

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

W33 Goat milk:

6 quarts low-fat goat milk No whole milk.

Juice:
Cereal: W35 Goat
milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate No more than 36 oz 6 quarts low-fat goat milk No whole milk.

Juice:
W36 Goat milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 8 quarts low-fat goat milk No whole milk.

Juice:

W25

Peanut butter: Eggs: Cereal:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate
1 container (16 to 18 oz) 1 dozen No more than 18 oz

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Fish:

No more than 15 oz

FP-158

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number W65 Tofu for Exclusively Breastfeeding Multiples Package A
$15 fruit and vegetable
8 gallon milk
2 lb cheese

VC Voucher Message P04 Produce: $15 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. W82 Milk: 2 gallons only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

4 lb tofu 4-48 oz juice 3 dozen eggs 54 oz cereal 16 oz whole grain 1 container of peanut butter (16-18 oz.) 2 lb dried beans 45 oz fish

Juice
Eggs: Cereal: W03 Milk:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen No more than 36 oz.
2 gallons only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

Peanut

butter: 1 container (16 to 18 oz)

Fish:

No more than 30 oz

029 Milk: 2 gallons only low-fat (fat-free, 1%,

2%) No whole milk.

Least expensive brand

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-159

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

031 Milk:

1 gallon only low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand

Juice: 1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate
Cheese: 1-16 oz package W23 Milk: 1 gallon only low-fat (fat-free, 1%, 2%)
No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: No more than 18 oz. W38 Tofu: 4 pounds

Whole Grain:
Beans W24 Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried or 4 cans (14 to 16 oz) 1 dozen eggs

Beans: 1 lb dried or 4 cans (14 to 16 oz)

Fish: No more than 15 oz.

FP-160

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number VC Voucher Message

V65 (Assign W65)

P04 Produce $15 for fresh, frozen, or canned fruit

Tofu for Exclusively

and vegetables

Breastfeeding Multiples

No potatoes-except for sweet potatoes

Package B

or yams. No products with added

$15 fruit and vegetables

sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or

8 gallons of milk

050 Milk:

diced tomatoes. 1 gallon low-fat (fat-free, 1%, 2%)

1 lb cheese

No whole milk. Least expensive brand

4 lb tofu 5-48 oz juice 3 dozen eggs 54 oz cereal 32 oz whole grains 2 containers of peanut butter (16-18 oz. each) 1 lb dried beans 45 oz fish

Juice:
Eggs: Cereal W03 Milk:
Cheese: Peanut butter: Fish: 029 Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen No more than 36 oz 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1-16 oz package
1 container (16 to 18 oz) No more than 30 oz 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-161

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

W23 Milk: Eggs:

1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1 dozen

Cereal: No more than 18 oz W53 Eggs: 1 dozen

Whole Grain:
Fish
W26 Milk:

Juice:

W39

Peanut butter: Beans: Tofu:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
No more than 15 oz 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate
1 container (16 to 18 oz) 1 lb dried or 4 cans (14 to 16 oz) 4 pounds

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

FP-162

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number W69 No milk for Exclusively Breastfeeding Multiples Package A
MEDICAL DOCUMENTATION REQUIRED

VC P04
W62

Voucher Message Produce: $15 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Cheese: 1-16 oz package

Can only be given with food package III $15 fruit and vegetables 2 lb cheese 4-48 oz cans juice 3 dozen eggs 54 oz cereal 16 oz whole grain 1 container of peanut butter (16-18 oz.) 2 lb dried beans 45 oz fish

Juice:

W08 Eggs: Whole Grain:

W24

Peanut Butter: Fish: Eggs:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 container (16-18 oz) No more than 30 oz 1 dozen

Beans: 1 lb dried or 4 cans (14 to 16 oz)

Fish:

No more than 15 oz

W54 Cheese: 1-16 oz package

Eggs: 1 dozen

Cereal: W63 Juice

No more than 36 oz 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate

Beans: 1 lb dried or 4 cans (14 to 16 oz)

Cereal: No more than 18 oz

FP-163

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package number V69 (Assign W69)No Milk for Exclusively Breastfeeding Multiples Package B
MEDICAL DOCUMENTATION REQUIRED

VC P04
W62

Voucher Message Produce: $15 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Cheese: 1-16 oz package

Can only be given with food package III $15 fruit and vegetable 1 lb cheese 5-48 oz juice 3 dozen eggs 54 oz cereal 32 oz whole grains 2 containers of peanut butter (16-18 oz. each) 1 lb dried beans 45 oz fish

Juice:

W66 W64

Eggs: Peanut Butter: Fish: Juice:

W65

Peanut butter: Beans: Juice:

Eggs:
Cereal: W25 Eggs:
Cereal:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate 1 dozen
1 container (16-18 oz) No more than 30 oz 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate
1 container (16 to 18 oz) 1 lb dried or 4 cans (14 to 16 oz) 1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate
1 dozen
No more than 36 oz 1 dozen No more than 18 oz

Whole grain:
Fish:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns No more than 15 oz

FP-164

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W71 Soy milk for Exclusively Breastfeeding Multiples Package A
$15 fruits and vegetables
9 gallons soy milk
2 lb cheese
4-48 oz juice
3 dozen eggs
54 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

VC P04
W74

Voucher message

Produce: $15 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Soy

4 half gallons 8th Continent

Milk: (Original flavor only)

Eggs: 1 dozen

Beans: W75 Soy
Milk:

1 lb dried or 4 cans (14 to 16 oz) 2 half gallons 8th Continent (Original flavor only)

W69

Cheese: Peanut Butter: Fish: Soy Milk:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz 2 half gallons 8th Continent (Original flavor only)

Juice:
Eggs: W76 Soy
Milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 4 half gallons 8th Continent (Original flavor only)

Cheese: 1-16 oz package

W77

Cereal: Soy Milk: Juice:

No more than 18 oz 2 half gallons 8th Continent (Original flavor only) 1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Cereal: No more than 36 oz

FP-165

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

W30 Soy Milk: Juice:
Whole Grain:
W78 Soy milk:
Eggs:
Beans:
Fish:

2 half gallons 8th Continent (Original flavor only) 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 2 half gallons 8th Continent (Original flavor only)
1 dozen
1 lb dried or 4 cans (14 to 16 oz)
No more than 15 oz

FP-166

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package V71 (Assign W71) Soy Milk for women Exclusively Breastfeeding Multiples Package B
$15 fruits and vegetables
9 gallons soy milk

VC P04
W74

Voucher message

Produce: $15 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Soy

4 half gallons 8th Continent

milk: (Original flavor only)

1 lb cheese

Eggs: 1 dozen

5-48 oz juice 3 dozen eggs

Beans: W75 Soy
milk:

1 lb dried or 4 cans (14 to 16 oz) 2 half gallons 8th Continent (Original flavor only)

54 oz cereal
32 oz whole grain
2 containers of peanut butter (16-18 oz. each)

W69

Cheese: Peanut butter: Fish: Soy milk:

1-16 oz package
1 container (16 to 18 oz) No more than 30 oz 2 half gallons 8th Continent (Original flavor only)

1 lb dried beans 45 oz fish

Juice:
Eggs: W77 Soy
milk:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 dozen 2 half gallons 8th Continent (Original flavor only)

Juice:

1 container (46-48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Cereal: W79 Soy
milk:

No more than 36 oz 4 half gallons 8th Continent (Original flavor only)

Juice:

2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable concentrate

FP-167

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

W81 Soy milk:

4 half gallons 8th Continent (Original flavor only)

Juice:

W25

Peanut butter: Eggs: Cereal:

1-46 oz container or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate
1 container (16 to 18 oz) 1 dozen No more than 18 oz

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Fish:

No more than 15 oz

FP-168

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13

Children 12 23 Month (C00-C19)

Food Package number VC Voucher Message

C01 - Standard Child 1-2 P03 Produce: $6 for fresh, frozen, or canned fruit

years old

and vegetables

$6 fruit and vegetables

No potatoes-except for sweet potatoes or yams. No products with added

4 gallon whole milk

sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or

2-64 oz juice

C03 Milk:

diced tomatoes. 1 gallon Whole milk only

1 dozen eggs

Least expensive brand

36 oz cereal

Juice: C04 Milk:

1-64 oz container 1 gallon Whole milk only

32 oz whole grain

Least expensive brand

1 lb beans

Cereal: No more than 36 oz

Eggs: 1 dozen

C03 Milk: 1 gallon Whole milk only

Least expensive brand

Juice: C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-169

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package

VC Voucher Message

C02 Lactose Intolerant P03 Produce: $6 for fresh, frozen, or canned fruit

1-2 year old

and vegetables

(No potatoes-except for sweet

$6 fruit and vegetable

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

16 quarts lactose reduced

No creamed vegetables. No stewed or

whole milk

diced tomatoes.

2-64 oz juice

C08 Milk:

1 gallon or 4 quarts or 2 half gallons whole lactose free, or Acidophilus, or

Acidophilus and Bifidum No low-fat

1 dozen eggs

milk. Least expensive brand

36 oz cereal 32 oz whole grains 1 lb beans

Juice: Eggs: C09 Milk:

1-64 oz container 1 dozen 1 gallon or 4 quarts or 2 half gallons whole lactose free, or Acidophilus, or Acidophilus and Bifidum No low-fat milk. Least expensive brand

Juice: Cereal: C10 Milk:

1-64 oz container No more than 36 oz 1 gallon or 4 quarts or 2 half gallons whole lactose free, or Acidophilus, or Acidophilus and Bifidum No low-fat milk. Least expensive brand

Beans: C12 Milk:

1 lb dried or 4 cans (14 to 16 oz) 1 gallon or 4 quarts or 2 half gallons whole lactose free, or Acidophilus, or Acidophilus and Bifidum No low-fat milk. Least expensive brand

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-170

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package C03 Goat Milk for 1-2 year old
$6 fruit and vegetable
16 quarts of whole goat milk or 21 quarts evaporated goat milk
2-64 oz juice

VC Voucher Message

P03 Produce: $6 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

C15 Goat

3 quarts whole goat milk or 4-12 oz

Milk: cans evaporated goat milk No low-fat

milk.

1 dozen eggs 36 oz cereal 32 oz whole grain 1 lb dried beans

Cereal: C18 Goat
Milk:

No more than 36 oz 3 quarts whole goat milk or 4-12 oz cans evaporated goat milk No low-fat milk.

Beans: C16 Goat
Milk:

1 lb dried or 4 cans (14 to 16 oz) 3 quarts whole goat milk or 4-12 oz cans evaporated goat milk No low-fat milk.

Juice: Eggs: C17 Goat Milk:

1-64 oz container 1 dozen 3 quarts whole goat milk or 4-12 oz cans evaporated goat milk No low-fat milk.

Juice: Whole grain:
A25 Goat Milk:

1-64 oz container Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 4 quarts whole goat milk or 5-12 oz cans evaporated goat milk. No low-fat milk.

FP-171

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package Number VC C05 Limited Tofu for 1- P03 2 yr old

MEDICAL DOCUMENTATION REQUIRED

$6 Fruit and vegetable

C03

3 gallon whole milk C04
4 lb tofu

Voucher Message Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Milk: 1 gallon Whole milk only Least expensive brand Juice: 1-64 oz container Milk: 1 gallon Whole milk only Least expensive brand only

2-64 oz juice 1 dozen eggs

Cereal: Eggs: C20 Tofu:

No more than 36 oz 1 dozen 4 pounds

36 oz cereal 32 oz whole grains

Juice: C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

1 lb dried beans

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-172

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package Number C06 Extra Tofu for 1-2 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
2 gallon whole milk
8 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. C20 Tofu: 4 pounds

Juice: C04 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs: C20 Tofu:

1 dozen 4 pounds

Juice: C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-173

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package C09 No Milk 1-2 year old
MEDICAL DOCUMENTAION REQUIRED
Can only be given with Food Package III
$6 fruit and vegetable
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb beans

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. C23 Juice: 1-64 oz container

Eggs: 1 dozen

Cereal: No more than 36 oz C24 Juice: 1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried or 4 cans (14 to 16 oz)

FP-174

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package C10 1-2 year old Alternative Package
$6 fruits and vegetables
64-8 oz UHT whole milk
21-6 oz juice

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. H06 Milk: 12-8 oz or half pint boxes whole UHT

36 oz cereal

Juice: 6 cans (5.5 to 6 oz)

32 oz whole grain 4-16 oz cans beans

Cereal: No more than 18 oz H07 Milk: 12-8 oz or half pint boxes whole UHT

Juice: H07 Milk:

6 cans (5.5 to 6 oz) 12-8 oz or half pint boxes whole UHT

Juice: H10 Milk:

6 cans (5.5 to 6 oz) 12-8 oz or half pint boxes whole UHT

Cereal: Not more than 18 oz H08 Milk: 16-8 oz or half pint boxes whole UHT

Juice: 3 cans (5.5 to 6 oz)

Whole grain:
Beans:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 4 cans (14 to 16 oz)

FP-175

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package C11 Soy Milk for 1 -2 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
4 gallons Soy Milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans

VC P03
W70

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed or

diced tomatoes.

Soy

2 half gallons 8th Continent

Milk: (Original flavor only)

Cereal: W57 Soy
Milk:

No more than 36 oz 2 half gallons 8th Continent (Original flavor only)

Beans: C28 Soy
Milk:

1 lb dried or 4 cans (14 to 16 oz) 2 half gallons 8th Continent (Original flavor only)

Juice: Eggs: C29 Soy Milk:

1-64 oz container 1 dozen 2 half gallons 8th Continent (Original flavor only)

Juice: Whole grain:

1-64 oz container Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-176

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14

Children 2 -5 Years (C20-C39)

Food Package C21 Standard 2-5 year old $6 fruit and vegetable
2 gallons milk
1-3 qt dry milk
1 lb cheese
264 oz juice
1 dozen eggs

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potato or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. C01 Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: W04 Milk:

2-64 oz containers 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

36 oz cereal 32 oz whole grain

Cheese: W05 Milk:

1 lb dried beans or 1 container of peanut butter (16-18 oz.)
C02

Eggs:
Cereal Dry milk: Whole Grain:

Beans/ peanut butter:

1-16 oz package 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
1 dozen
No more than 36 oz 1-3 quart non-fat dry powder
Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-177

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package

VC

C22- Lactose Intolerant P03

2-5 year old

$6 fruit and vegetable

13 quarts of lactose reduced milk
C11 1 lb cheese

2-64 oz juice

1 dozen eggs

36 oz cereal

033

32 oz whole grain

1 lb dried beans or 1 container of peanut butter (16-18 oz.)

045

C07

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit

and vegetables

No potatoes except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed

or diced tomatoes.

Milk:

1 gallon or 4 quarts or 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, or Acidophilus, or Acidophilus

and Bifidum. No whole milk. Least

expensive brand

Cheese: 1-16 oz package

Juice:

2-64 oz containers

Milk:

1 gallon or 4 quarts or 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, or Acidophilus, Acidophilus

and Bifidum.

No whole milk. Least expensive

brand

Cereal: Milk:
Beans/ peanut butter: Milk:
Eggs: Whole Grain:

No more than 36 oz 1 gallon or 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, Acidophilus and Bifidum. No whole milk. Least expensive brand
1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter 1 quart low-fat (fat-free, 1%, 2%) Lactose free, or Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand 1 dozen Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-178

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package C23 Goat Milk for 2-5 year old
$6 fruit and vegetable 13 quarts of goat milk
1 lb cheese
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grains
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC P03
W15

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed or

diced tomatoes.

Goat

4 quarts low-fat goat milk No whole

milk:

milk.

Cereal: W19 Goat
milk:

No more than 36 oz 1 quart low-fat goat milk. No whole Milk.

Cheese: 1-16 oz package

Beans/

Peanut 1 lb dried or 4 cans (14 to 16 oz) beans

butter: or 1 container (16 to 18 oz) peanut

butter

C13 Goat

4 quarts low-fat goat milk No whole

milk:

milk.

Juice: Eggs: C14 Goat Milk:

1-64 oz container 1 dozen 4 quarts low-fat goat milk No whole milk.

Juice: 1-64 oz container

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-179

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number VC Voucher Message

C24 Extra Cheese for 2- P03 Produce: $6 for fresh, frozen, or canned fruit

5 year old child

and vegetables

MEDICAL

No potatoes-except for sweet potatoes or yams. No products with

DOCUMENTATION REQUIRED

added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed

$6 Fruit and vegetable

C01 Milk:

or diced tomatoes. 1 gallon low-fat (fat-free, 1%, 2%)

2 gallon milk

No whole milk. Least expensive brand

2 lb cheese 2-64 oz juice 1 dozen eggs 36 oz cereal 32 oz whole grain

Juice: W04 Milk:
Cheese: W05 Milk:

2-64 oz containers 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
1-16 oz package 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

1 lb dried beans or 1 container of peanut butter (16-18 oz.)
C21

Eggs:
Cereal Beans/ peanut butter:

1 dozen
No more than 36 oz. 1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Cheese: 1-16 oz package

FP-180

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number VC Voucher Message

C25- Limited Tofu for 2- P03 Produce: $6 for fresh, frozen, or canned fruit

5 year old child

and vegetables

No potatoes-except for sweet

MEDICAL DOCUMENTATION REQUIRED

potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or

$6 Fruit and vegetable

C01 Milk:

diced tomatoes. 1 gallon low-fat (fat-free, 1%, 2%)

3 gallon milk

No whole milk. Least expensive brand

4 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Juice: C19 Milk:
Whole Grain: W05 Milk:
Eggs:

2-64 oz containers 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
1 dozen

Cereal: No more than 36 oz W42 Tofu: 4 pounds

Bean/ Peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-181

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number C26 Extra Tofu for 2-5 year old child
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
2 gallon milk
8 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. C06 Tofu: 4 pounds

Juice: C19 Milk:

2-64 oz containers 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
W05 Milk:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: No more than 36 oz. W42 Tofu: 4 pounds

Beans/ Peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-182

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number VC Voucher Message

C27 Whole Milk for 2 - P03 Produce: $6 for fresh, frozen, or canned fruit

5 year old

and vegetables

No potatoes-except for sweet

MEDICAL DOCUMENTATION REQUIRED

potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or

Can only be given with C03 Milk: food package III

diced tomatoes. 1 gallon Whole milk only Least expensive brand

$6 fruit and vegetable 4 gallon milk

Juice: C04 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

2-64 oz juice

Cereal: No more than 36 oz

1 dozen eggs 36 oz cereal

Eggs: C03 Milk:

1 dozen 1 gallon Whole milk only Least expensive brand

32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Juice: C22 Milk:
Whole Grains:

1-64 oz container
1 gallon Whole milk only Least expensive brand Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans/ peanut Butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-183

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package C28 No Cheese for 2-5 year old
$6 fruit and vegetable
4 gallon milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC P03
C01 W05

Voucher Message Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand Juice: 2-64 oz containers Milk: 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: W22 Milk:

No more than 36 oz
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Beans/ peanut butter: C19 Milk:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter
1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-184

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package C29 No Milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED
Can only be given with Food Package III
$6 fruit and vegetable
1 lb cheese
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb beans or 1 container of peanut butter (16-18 oz.)

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. C27 Cheese: 1-16 oz package Juice: 1-64 oz container

Eggs: 1 dozen

Cereal: No more than 36 oz C26 Juice: 1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans/ peanut butter:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter

FP-185

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package C30 2-5 year old Alternative Package
$6 fruit and vegetable
64-8 oz UHT milk
21-6 oz juice
36 oz cereal
32 oz whole grain
1 container of peanut butter (16-18 oz.)
4 cans beans

VC Voucher Message P03 Produce: $6 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. H12 Milk: 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Juice: 6 cans (5.5 to 6 oz)

Cereal: H15 Milk:

No more than 18 oz 12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice: 6 cans (5.5 to 6 oz)

Peanut butter: H11 Milk:

1 container (16 to 18 oz) 12-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice: 6 cans (5.5 to 6 oz)

Beans: H13 Milk:

4 cans (14 to 16 oz) 12-8 oz or half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Cereal: H09 Milk:

Not more than 18 oz 16-8 oz or half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice: 3 cans (5.5 to 6 oz)

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-186

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package C31 Soy Milk for 2 -5 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
4 gallons soy milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

VC P03
W70

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet

potatoes or yams. No products with

added sugar, seasonings, fat, or oils.

No creamed vegetables. No stewed or

diced tomatoes.

Soy

2 half gallons 8th Continent

Milk: (Original flavor only)

Cereal: W73 Soy
Milk:

No more than 36 oz 2 half gallons 8th Continent (Original flavor only)

Beans/ peanut butter: C28 Soy Milk:

1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter 2 half gallons 8th Continent (Original flavor only)

Juice: Eggs: C29 Soy Milk:

1-64 oz container 1 dozen 2 half gallons 8th Continent (Original flavor only)

Juice: Whole grain:

1-64 oz container Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-187

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15

Special Formula Summary

CPA FPC
R01 R01 R01
S01 X01
R03 R03 R03
S03 X03
X39 X40 X02 X42
X86 X34 X35 X36
R11 R11 R11
S11 X89
R41 R41 R41

Status / Age
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
Women Women Women Women
Child Child Child Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m

System FPC
R01 S01 T01
S01 X01
R03 S03 T03
S03 X03
X39 X40 X02 X42
X86 X34 X35 X36
R11 S11 T11
S11 X89
R41 S41 T41

Formula
Powder Alimentum 7-16 oz cans powder Alimentum 8-16 oz cans powder Alimentum 6-16 oz cans powder Alimentum 32 jars baby fruit/vegetable 3-8 oz box infant cereal 8-16 oz cans powder Alimentum 8-16 oz cans powder Alimentum
RTF Alimentum 26-32 oz cans RTF Alimentum 28-32 oz cans RTF Alimentum 20-32 oz cans RTF Alimentum 32 jars baby fruit/vegetable 3-8 oz box infant cereal 28-32 oz cans RTF Alimentum 28-32 oz cans RTF Alimentum
Boost 30-8 oz containers Boost 60-8 oz containers Boost 90-8 oz containers Boost 112-8 oz containers Boost
Bright Beginnings Soy Pediatric Drink 30-8 oz containers Bright Beginnings Soy Pediatric Drink 60-8 oz containers Bright Beginnings Soy Pediatric Drink 90-8 oz containers Bright Beginnings Soy Pediatric Drink 108-8 oz containers Bright Beginnings Soy Pediatric Drink
Powder EleCare 9-14.1 oz cans powder EleCare 10-14.1 oz cans powder EleCare 7-14.1 oz cans powder EleCare 32 jars baby fruit/vegetable 3-8 oz box infant cereal 10-14.1 oz cans powder EleCare 9-14.1 oz cans powder EleCare
Powder EleCare with DHA and ARA 9-14.1 oz cans powder EleCare with DHA and ARA 10-14.1 oz cans powder EleCare with DHA and ARA 7-14.1 oz cans powder EleCare with DHA and ARA

FP-188

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15 (cont'd)

CPA FPC
S41

Status / Age FFF 6-11 m

System FPC
S41

Formula
32 jars baby fruit/vegetable 3-8 oz box infant cereal 10-14.1 oz cans powder EleCare with DHA and ARA

Enfamil EnfaCare LIPIL Powder

R24 FFF 0-3 m R24 10-12.8 oz cans powder EnfaCare LIPIL

R24 FFF 4-5 m S24 11-12.8 oz cans powder EnfaCare LIPIL

R24 FFF 6-11 m T24 8-12.8 oz cans powder EnfaCare LIPIL

32 jars baby fruit/vegetable

3-8 oz box infant cereal

S24 FFF 6-11 m S24 11-12.8 oz cans powder EnfaCare LIPIL

X78

Child

X78 11-12.8 oz cans powder EnfaCare LIPIL

Enfamil EnfaCare LIPIL RTF - 32 oz

R26 FFF 0-3 m R26 26-32 oz cans RTF EnfaCare LIPIL

R26 FFF 4-5 m S26 28-32 oz cans RTF EnfaCare LIPIL

R26 FFF 6-11 m T26 20-32 oz cans RTF EnfaCare LIPIL

32 jars baby fruit/vegetable

3-8 oz box infant cereal

S26 FFF 6-11 m S26 28-32 oz cans RTF EnfaCare LIPIL

X79

Child

X79 28-32 oz cans RTF EnfaCare LIPIL

Enfamil EnfaCare LIPIL RTF - 2 oz

R20 FFF 0-3 m R20 414-2 oz cans RTF EnfaCare LIPIL

R20 FFF 4-5 m S20 444-2 oz cans RTF EnfaCare LIPIL

R20 FFF 6-11 m T20 318-2 oz cans RTF EnfaCare LIPIL

32 jars baby fruit/vegetable

3-8 oz box infant cereal

S20 FFF 6-11 m S20 444-2 oz cans RTF EnfaCare LIPIL

Enfamil Premature LIPIL 20 RTF - 2 oz

R30 FFF 0-3 m R30 414-2 oz cans RTF Enfamil Premature LIPIL 20

R30 FFF 4-5 m S30 444-2 oz cans RTF Enfamil Premature LIPIL 20

R30 FFF 6-11 m T30 318-2 oz cans RTF Enfamil Premature LIPIL 20

32 jars baby fruit/vegetable

3-8 oz box infant cereal

S30 FFF 6-11 m S30 444-2 oz cans RTF Enfamil Premature LIPIL 20

Enfamil Premature LIPIL 24 RTF-2 oz R40 FFF 0-3 m R40 414-2 oz cans RTF Enfamil Premature LIPIL 24 R40 FFF 4-5 m S40 444-2 oz cans RTF Enfamil Premature LIPIL 24

FP-189

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15 (cont'd)

CPA FPC R40
S40
X06 X38 X45 X15
X47 X48 X49 X50
X51 X52 X53
R51 R51 R51
S51
R61 R61 R61
S61

Status / Age FFF 6-11 m
FFF 6-11 m
Women Women Women Women
Women Women Women Women
Child Child Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m

System FPC T40
S40
X06 X38 X45 X15
X47 X48 X49 X50
X51 X52 X53
R51 S51 T51
S51
R61 S61 T61
S61

Formula
318-2 oz cans RTF Enfamil Premature LIPIL 24 32 jars baby fruit/vegetable 3-8 oz box infant cereal 444-2 oz cans RTF Enfamil Premature LIPIL 24
Ensure 30-8 oz containers Ensure 60-8 oz containers Ensure 90-8 oz containers Ensure 108-8 oz containers Ensure
Ensure Fiber 30-8 oz containers Ensure Fiber 60-8 oz containers Ensure Fiber 90-8 oz containers Ensure Fiber 108-8 oz containers Ensure Fiber
EO28 Splash 31-237 ml containers EO28 Splash 62-237 ml containers EO28 Splash 112-237 ml containers EO28 Splash
Powder Neocate Infant 10-400 grams (14.1 oz) cans powder Neocate Infant 11-400 grams (14.1 oz) cans powder Neocate Infant 8-400 grams (14.1 oz) cans powder Neocate Infant 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-400 grams (14.1 oz) cans powder Neocate Infant
Powder Neocate Infant DHA & ARA 10-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA 11-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA 8-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA

FP-190

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15 (cont'd)

CPA FPC
X72 X77 X74
X75
R71 R71 R71
S71 X92
R73 R73 R73
S73 X73
R70 R70 R70
S70
R81 R81 R81
S81 X81

Status / Age
Child Child Child
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child

System FPC
X72 X77 X74
X75
R71 S71 T71
S71 X92
R73 S73 T73
S73 X73
R70 S70 T70
S70
R81 S81 T81
S81 X81

Formula
Powder Neocate One+ 30-60 grams packets powder Neocate One+ 60-60 grams packets powder Neocate One+ 113-60 grams packets powder Neocate One+
Powder Neocate Junior 14-400 grams (14.1 oz) cans powder Neocate Junior
Powder NeoSure 10-12.8 oz cans powder Similac NeoSure 11-12.8 oz cans powder Similac NeoSure 8-12.8 oz cans powder Similac NeoSure 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-12.8 oz cans powder Similac NeoSure 10-12.8 oz cans powder Similac NeoSure
RTF NeoSure 32 oz 26-32 oz cans RTF Similac NeoSure 28-32 oz cans RTF Similac NeoSure 20-32 oz cans RTF Similac NeoSure 32 jars baby fruit/vegetable 3-8 oz box infant cereal 28-32 oz cans RTF Similac NeoSure 28-32 oz cans RTF Similac NeoSure
RTF NeoSure 2 oz 416-2 oz cans RTF NeoSure 448-2 oz cans RTF NeoSure 320-2 oz cans RTF NeoSure 32 jars baby fruit/vegetable 3-8 oz box infant cereal 448-2 oz cans RTF NeoSure
Powder Nutramigen LIPIL with Enflora LGG 10-12.6 oz cans powder Nutramigen LIPIL with Enflora IGG 11-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 8-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 10-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

FP-191

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15 (cont'd)

CPA FPC
R82 R82 R82
S82 X82
R83 R83 R83
S83 X83
R91 R91 R91
S91
X54 X55 X56
X57 X58 X59
X60 X37 X62
X84 X30 X87

Status / Age
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m
Women Women Women
Child Child Child
Child Child Child
Child Child Child

System FPC
R82 S82 T82
S82 X82
R83 S83 T83
S83 X83
R91 S91 T91
S91
X54 X55 X56
X57 X58 X59
X60 X37 X62
X84 X30 X87

Formula
Concentrate Nutramigen LIPIL 31-13 oz cans concentrate Nutramigen LIPIL 34-13 oz cans concentrate Nutramigen LIPIL 24-13 oz cans concentrate Nutramigen LIPIL 32 jars baby fruit/vegetable 3-8 oz box infant cereal 34-13 oz cans concentrate Nutramigen LIPIL 35-13 oz cans concentrate Nutramigen LIPIL
RTF Nutramigen LIPIL 32 oz 26-32 oz cans RTF Nutramigen LIPIL 28-32 oz cans RTF Nutramigen LIPIL 20-32 oz cans RTF Nutramigen LIPIL 32 jars baby fruit/vegetable 3-8 oz box infant cereal 28-32 oz cans RTF Nutramigen LIPIL 28-32 oz cans RTF Nutramigen LIPIL
Powder Nutramigen AA LIPIL 8-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 9-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 7-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 32 jars baby fruit/vegetable 3-8 oz box infant cereal 9-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL
Nutren 2.0 35-250 ml containers Nutren 2.0 59-250 ml containers Nutren 2.0 107-250 ml containers Nutren 2.0
Nutren Junior 35-250 ml containers Nutren Junior 59-250 ml containers Nutren Junior 107-250 ml containers Nutren Junior
Nutren Junior Fiber 35-250 ml containers Nutren Junior Fiber 59-250 ml containers Nutren Junior Fiber 107-250 ml containers Nutren Junior Fiber
Ready to Feed PediaSure 30-8 oz containers PediaSure 60-8 oz containers PediaSure 90-8 oz containers PediaSure

FP-192

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15 (cont'd)

CPA FPC X88
X76 X85 X78 X79
X63 X64 X65
X66 X67 X68
X69 X70 X05
X20
R04 R04 R04
S04 X04
R14 R14 R14
R14
S14 X14

Status / Age

System FPC

Formula

Child

X88 108-8 oz containers PediaSure

Child Child Child Child
Women Women Women
Child Child Child
Child Child Child
Child
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6 m
FFF 7-11 m
FFF 6-11 m Child

Ready to Feed PediaSure with Fiber X76 30-8 oz containers PediaSure with Fiber X85 60-8 oz containers PediaSure with Fiber X78 90-8 oz containers PediaSure with Fiber X79 108-8 oz containers PediaSure with Fiber
Peptamen X63 35-250 ml containers Peptamen X64 59-250 ml containers Peptamen X65 107-250 ml containers Peptamen
Peptamen Junior X66 35-250 ml containers Peptamen Junior X67 59-250 ml containers Peptamen Junior X68 107-250 ml containers Peptamen Junior
Peptamen Junior with Prebio X69 35-250 ml containers Peptamen Junior with Prebio X70 59-250 ml containers Peptamen Junior with Prebio X05 107-250 ml containers Peptamen Junior with Prebio
Powder Portagen X20 13-1 lb cans powder Portagen
Powder Pregestimil R04 7-16 oz cans powder Pregestimil S04 8-16 oz cans powder Pregestimil T04 6-16 oz cans powder Pregestimil
32 jars baby fruit/vegetable 3-8 oz box infant cereal S04 8-16 oz cans powder Pregestimil X04 8-16 oz cans powder Pregestimil
Powder Similac PM 60/40 R14 8-14.1 oz cans powder Similac PM 60/40 S14 9-14.1 oz cans powder Similac PM 60/40 V14 7-14.1 oz cans powder Similac PM 60/40
32 jars baby fruit/vegetable 3-8 oz box infant cereal T14 6-14.1 oz cans powder Similac PM 60/40 32 jars baby fruit/vegetable 3-8 oz box infant cereal S14 9-14.1 oz cans powder Similac PM 60/40 X14 8-14.1 oz cans powder Similac PM 60/40

FP-193

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-15 (cont'd)

CPA FPC
R10 R10 R10
S10
R50 R50 R50
S50
R60 R60 R60
S60
099 197 199

Status / Age
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
All All All

System FPC
R10 S10 T10
S10
R50 S50 T50
S50
R60 S60 T60
S60
099 197 199

Formula
RTF Similac Special Care 20 2 oz 416-2 oz cans RTF Similac Special Care 20 448-2 oz cans RTF Similac Special Care 20 320-2 oz cans RTF Similac Special Care 20 32 jars baby fruit/vegetable 3-8 oz box infant cereal 448-2 oz cans RTF Similac Special Care 20
RTF Similac Special Care 24 2 oz 416-2 oz cans RTF Similac Special Care 24 448-2 oz cans RTF Similac Special Care 24 320-2 oz cans RTF Similac Special Care 24 32 jars baby fruit/vegetable 3-8 oz box infant cereal 448-2 oz cans RTF Similac Special Care 24
RTF Similac Special Care 30 2 oz 416-2 oz cans RTF Similac Special Care 30 448-2 oz cans RTF Similac Special Care 30 320-2 oz cans RTF Similac Special Care 30 32 jars baby fruit/vegetable 3-8 oz box infant cereal 448-2 oz cans RTF Similac Special Care 30
Tracking Vouchers Emory Genetics tracking voucher Formula Provided from stock on hand Formula ordered from office of Nutrition

FP-194

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16

Alimentum
Food Package Code R01 7-16 oz cans powder Alimentum

Special Non-Contract Infant Formulas Infant Fully Formula Fed
VC Voucher Message 360 Formula 4-16 oz cans powder Alimentum S01 Formula 3-16 oz cans powder Alimentum

Medical Documentation

Required

S01 (Assign R01)

360

8-16 oz cans powder Alimentum

360

Formula 4-16 oz cans powder Alimentum Formula 4-16 oz cans powder Alimentum

Medical Documentation

Required

T01 (Assign R01)

S01

6-16 oz cans powder

S01

Alimentum

N26

32-4 oz infant food N01
3-8 oz infant cereal

Medical Documentation Required

R03

130

26-32 oz containers ready

to feed Alimentum

130

Medical Documentation Required

Formula Formula Infant foods:
Infant foods:
Infant cereal: Formula
Formula

3-16 oz cans powder Alimentum
3-16 oz cans powder Alimentum 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 13-32 oz containers ready to feed Alimentum 13-32 oz containers ready to feed Alimentum

FP-195

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

S03 (Assign R03)

150

28-32 oz containers ready

to feed Alimentum

150

Medical Documentation Required

Formula Formula

14-32 oz containers ready to feed Alimentum 14-32 oz containers ready to feed Alimentum

T03 (Assign R03)

N05

20-32 oz containers ready

to feed Alimentum

N05

32-4 oz infant food

N26

3-8 oz infant cereal
N01 Medical Documentation Required

Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

10-32 oz containers ready to feed Alimentum 10-32 oz containers ready to feed Alimentum 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-196

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

EleCare Food Package Code R11 9-14.1 oz cans powder EleCare

VC Voucher Message 532 Formula 6-14.1 oz cans powder EleCare (1
case) 533 Formula 3-14.1 oz cans powder EleCare

Medical Documentation

Required

S11 (Assign R11)

532

10-14.1 oz cans powder

EleCare

534

Formula Formula

6-14.1 oz cans powder EleCare (1 case) 4-14.1 oz cans powder EleCare

Medical Documentation

Required

T11 (Assign R11)

532 Formula

7-14.1 oz cans powder EleCare

300 Formula N26 Infant

32-4 oz infant food

foods:

3-8 oz infant cereal

N01 Infant foods:

Medical Documentation Required

Infant cereal:

6-14.1 oz cans powder EleCare (1 case) 1-14.1 oz can powder EleCare 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-197

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

EleCare with DHA and ARA

Food Package Code

VC

R41

S33

9-14.1 oz cans powder

EleCare with DHA and S34

ARA

Voucher Message Formula 6-14.1 oz cans powder EleCare with
DHA and ARA (1 case) Formula 3-14.1 oz cans powder EleCare with
DHA and ARA

Medical Documentation

Required

S41 (Assign R41)

S33

10-14.1 oz cans powder

EleCare with DHA and S35

ARA

Formula Formula

6-14.1 oz cans powder EleCare with DHA and ARA (1 case) 4-14.1 oz cans powder EleCare with DHA and ARA

Medical Documentation

Required

S33 T41 (Assign R41)

7-14.1 oz cans powder EleCare with DHA and

S36

ARA

N26

32-4 oz infant food

3-8 oz infant cereal

N01

Medical Documentation Required

Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

6-14.1 oz cans powder EleCare with DHA and ARA (1 case) 1-14.1 oz can powder EleCare with DHA and ARA 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-198

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

EnfaCare LIPIL

Food Package Code

VC

R24

541

10-12.8 oz cans powder

Enfamil EnfaCare LIPIL 542

Medical Documentation

Required

S24 (Assign R24)

541

11-12.8 oz cans powder

Enfamil EnfaCare LIPIL S11

Medical Documentation Required
542
T24 (Assign R24) 8-12.8 oz cans powder 542 Enfamil EnfaCare LIPIL
N26 32-4 oz infant food

3-8 oz infant cereal

N01

Medical Documentation Required

R26

543

26-32 oz containers ready

to feed Enfamil EnfaCare 543 LIPIL

543 Medical Documentation

Required

543

S13

S26 (Assign R26)

543

28-32 oz containers ready

to feed Enfamil EnfaCare 543

LIPIL

543 Medical Documentation

Voucher Message Formula 6-12.8 oz cans powder Enfamil
EnfaCare LIPIL Formula 4-12.8 oz cans powder Enfamil
EnfaCare LIPIL

Formula Formula

6-12.8 oz cans powder Enfamil EnfaCare LIPIL 5-12.8 oz cans powder Enfamil EnfaCare LIPIL

Formula
Formula
Infant foods:
Infant foods: Infant cereal: Formula
Formula
Formula
Formula
Formula
Formula
Formula
Formula

4-12.8 oz cans powder Enfamil EnfaCare LIPIL 4-12.8 oz cans powder Enfamil EnfaCare LIPIL 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 2-32 oz containers ready to feed Enfamil EnfaCare LIPIL 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case)

FP-199

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC

Required

543

S12

T26 (Assign R26)

543

20-32 oz containers ready

to feed Enfamil EnfaCare 543

LIPIL

543 32-4 oz infant food

S13 3-8 oz infant cereal

N26 Medical Documentation
Required

N01

R20

589

414-2 oz containers ready

to feed Enfamil EnfaCare 589

LIPIL

589 Medical Documentation

Required

589

540

S20

S20 (Assign R20)

589

444-2 oz containers ready

to feed Enfamil EnfaCare 589 LIPIL

589 Medical Documentation

Required

589

539

Voucher Message

Formula 6-32 oz containers ready to feed

Enfamil EnfaCare LIPIL (1 case)

Formula 4-32 oz containers ready to feed

Enfamil EnfaCare LIPIL

Formula 6-32 oz containers ready to feed

Enfamil EnfaCare LIPIL (1 case)

Formula 6-32 oz containers ready to feed

Enfamil EnfaCare LIPIL (1 case)

Formula 6-32 oz containers ready to feed

Enfamil EnfaCare LIPIL (1 case)

Formula 2-32 oz containers ready to feed

Enfamil EnfaCare LIPIL

Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

cereal: 3-8 oz containers

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (1 case)

Formula 18-2 oz containers ready to feed

Enfamil EnfaCare LIPIL

Formula 12-2 oz containers ready to feed

Enfamil EnfaCare LIPIL

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare LIPIL (2 case)

Formula 48-2 oz containers ready to feed

FP-200

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC Voucher Message Enfamil EnfaCare LIPIL (1 case)
S20 Formula 12-2 oz containers ready to feed Enfamil EnfaCare LIPIL

T20 (Assign R20)

589

318-2 oz containers ready

to feed Enfamil EnfaCare 589

LIPIL

589 32-4 oz infant food

540 3-8 oz infant cereal

S20

Medical Documentation

Required

N26

N01

Formula
Formula
Formula
Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 cases) 18-2 oz containers ready to feed Enfamil EnfaCare LIPIL 12-2 oz containers ready to feed Enfamil EnfaCare LIPIL 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-201

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Enfamil Premature LIPIL 20

Food Package Code

VC

R30

595

414-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL 595

20

Medical Documentation 595 Required

595

546

S21

S30 (Assign R30)

595

444-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL 595

20

595 Medical Documentation Required
595

545

S21

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL20 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL20 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

T30 (Assign R30)

595

318-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL 595

20

Formula Formula

96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases)

FP-202

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC

32-4 oz infant food

595

3-8 oz infant cereal 546
Medical Documentation Required
S21

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20
Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

N26 Infant foods:
N01 Infant foods:
Infant cereal:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-203

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Enfamil Premature 24

Food Package Code

VC

R40

597

414-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL 597

24

Medical Documentation 597 Required

597

548

S22

S40 (Assign R40)

597

444-2 oz containers ready

to feed Enfamil

Premature LIPIL 24

597

Medical Documentation 597 Required
597

547

S22

T40 (Assign R40)

597

318-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL 597

24

32-4 oz infant food

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 24 (2 case) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases)

FP-204

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC Voucher Message

597 Formula 96-2 oz containers ready to feed iron

3-8 oz infant cereal

fortified Enfamil Premature LIPIL 24

(2 cases)

Medical Documentation S22 Formula 12-2 oz containers ready to feed iron

Required

fortified Enfamil Premature LIPIL 24

548 Formula 18-2 oz containers ready to feed iron

fortified Enfamil Premature LIPIL 24

N26 Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

N01 Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-205

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Neocate Infant

Food Package Code

VC Voucher Message

R51

506 Formula 4-400 gram (14.1 oz) cans powder

10-400 gram (14.1 oz)

Neocate Infant

cans powder Neocate

506 Formula 4-400 gram (14.1 oz) cans powder

Infant

Neocate Infant

507 Formula 1-400 gram (14.1 oz) can powder Neocate

Medical Documentation

Infant

Required

507 Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

S51 (Assign R51)

506 Formula 4-400 gram (14.1 oz) cans powder

11-400 gram (14.1 oz)

Neocate Infant

cans powder Neocate

506 Formula 4-400 gram (14.1 oz) cans powder

Infant

Neocate Infant

507 Formula 1-400 gram (14.1 oz) can powder Neocate

Medical Documentation

Infant

Required

507 Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

507 Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

T51 (Assign R51)

506 Formula 4-400 gram (14.1 oz) cans powder

8-400 gram (14.1 oz) cans

Neocate Infant

powder Neocate Infant 506 Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant

32-4 oz infant food

N26 Infant

16-4 oz containers baby food fruit

3-8 oz infant cereal

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-206

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Neocate Infant DHA & ARA

Food Package Code

VC

R61

500

10-400 gram (14.1 oz)

cans powder Neocate

500

Infant DHA & ARA

505 Medical Documentation

Required

505

S61 (Assign R61)

500

11-400 gram (14.1 oz)

500

cans powder Neocate

Infant DHA & ARA

505

Medical Documentation 505 Required
505

500 T61 (Assign R61)

8-400 gram (14.1 oz) cans powder Neocate Infant

500

DHA & ARA

N26

32-4 oz infant food

3-8 oz infant cereal

N01

Medical Documentation Required

Voucher Message

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-207

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Similac NeoSure

Food Package Code VC

R71

519

10-12.8 oz cans powder

Similac NeoSure

520 Medical Documentation

Required

S71 (Assign R71)

519

11-12.8 oz cans powder

Similac NeoSure

S25

Medical Documentation

Required

T71 (Assign R71)

520

8-12.8 oz cans powder

Similac NeoSure

520

32-4 oz infant food

N26

3-8 oz infant cereal
N01 Medical Documentation Required

R73

517

26-32 oz containers ready

to feed Similac NeoSure 517

Medical Documentation 517 Required
517

Voucher Message Formula 6-12.8 oz cans powder Similac
NeoSure (1 case) Formula 4-12.8 oz cans powder Similac NeoSure

Formula Formula

6-12.8 oz cans powder Similac NeoSure (1 case) 5-12.8 oz cans powder Similac NeoSure

Formula
Formula
Infant foods:
Infant foods:
Infant cereal: Formula
Formula
Formula
Formula

4-12.8 oz cans powder Similac NeoSure 4-12.8 oz cans powder Similac NeoSure 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case)

FP-208

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

S10

S73 (Assign R73)

517

28-32 oz containers ready

to feed Similac NeoSure 517

Medical Documentation 517 Required
517

S09

T73 (Assign R73)

517

20-32 oz containers ready

to feed Similac NeoSure 517

32-4 oz infant food 517
3-8 oz infant cereal

S10 Medical Documentation

Required

N26

N01

R70

596

416-2 oz containers ready

to feed Similac NeoSure 596

Medical Documentation 596 Required
596

516

Formula
Formula
Formula
Formula Formula
Formula Formula
Formula
Formula
Formula Infant foods: Infant foods: Infant cereal: Formula Formula Formula Formula Formula

2-32 oz containers ready to feed Similac NeoSure
6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case) 6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case) 4-32 oz containers ready to feed Similac NeoSure
6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case) 2-32 oz containers ready to feed Similac NeoSure 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 16-2 oz containers ready to feed Similac NeoSure

FP-209

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

516

S70 (Assign R70)

596

448-2 oz containers ready

to feed Similac NeoSure 596

Medical Documentation 596 Required
596

515

516

T70 (Assign R70)

596

320-2 oz containers ready

to feed Similac NeoSure 596

32-4 oz infant food

596

3-8 oz infant cereal

516

Medical Documentation 516 Required
N26

N01

Formula
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Infant foods: Infant foods: Infant cereal:

16-2 oz containers ready to feed Similac NeoSure
96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 48-2 oz containers ready to feed Similac NeoSure (1 case) 16-2 oz containers ready to feed Similac NeoSure 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 16-2 oz containers ready to feed Similac NeoSure 16-2 oz containers ready to feed Similac NeoSure 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-210

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Nutramigen LIPIL

Food Package Code

VC Voucher Message

R82

N08 Formula 15-13 oz cans concentrate

31-13 oz cans concentrate

Nutramigen LIPIL

Nutramigen LIPIL

N67 Formula 16-13 oz cans concentrate

Nutramigen LIPIL

Medical Documentation

Required

S82 (Assign R82)

N08 Formula 15-13 oz cans concentrate

34-13 oz cans concentrate

Nutramigen LIPIL

Nutramigen LIPIL

N57 Formula 19-13 oz cans concentrate

Nutramigen LIPIL

Medical Documentation

Required

163 T82 (Assign R82)

24-13 oz cans concentrate Nutramigen LIPIL

163

Formula Formula

12-13 oz cans concentrate Nutramigen LIPIL 12-13 oz cans concentrate Nutramigen LIPIL

32-4 oz infant food

N26 Infant foods:

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

3-8 oz infant cereal

N01 Infant

foods single ingredient only) 16-4 oz containers baby food fruit

Medical Documentation Required

foods: Infant

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

cereal: 3-8 oz containers

R81

156 Formula 5-12.6 oz cans powder Nutramigen

1012.6 oz cans powder

LIPIL with Enflora LGG

Nutramigen LIPIL with 156 Formula 5-12.6 oz cans powder Nutramigen

Enflora LGG

LIPIL with Enflora LGG

Medical Documentation

Required

S81 (Assign R81)

156

11-12.6 oz cans powder

Formula 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

FP-211

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC

Nutramigen LIPIL with 155

Enflora LGG

Medical Documentation Required

Voucher Message Formula 6-12.6 oz cans powder
Nutramigen LIPIL with Enflora LGG

T81 (Assign R81)

156

8-12.6 oz cans powder

Nutramigen LIPIL with S32 Enflora LGG

N26 32-4 oz infant food

3-8 oz infant cereal

N01

Medical Documentation Required

R83

S30

26-32 oz containers ready

to feed Nutramigen

S30

LIPIL

Formula
Formula
Infant foods:
Infant foods:
Infant cereal: Formula
Formula

5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 3-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers 13-32 oz containers ready to feed Nutramigen LIPIL 13-32 oz containers ready to feed Nutramigen LIPIL

Medical Documentation

Required

S83 (Assign R83)

S03

28-32 oz containers ready

to feed Nutramigen

S03

LIPIL

Formula Formula

14-32 oz containers ready to feed Nutramigen LIPIL 14-32 oz containers ready to feed Nutramigen LIPIL

Medical Documentation

Required

T83 (Assign R83)

S29

20-32 oz containers ready

to feed Nutramigen

S29

LIPIL

N26 32-4 oz infant food

Formula
Formula
Infant foods:

10-32 oz containers ready to feed Nutramigen LIPIL 10-32 oz containers ready to feed Nutramigen LIPIL 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd

FP-212

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC Voucher Message

foods single ingredient only)

3-8 oz infant cereal

N01 Infant

16-4 oz containers baby food fruit

Medical Documentation Required

foods: Infant

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

cereal: 3-8 oz containers

FP-213

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Nutramigen AA LIPIL

Food Package Code

VC Voucher Message

R91

706 Formula 4-400 gram (14.1 oz) cans powder

8-14.1 oz cans powder

Nutramigen AA LIPIL

Nutramigen AA LIPIL 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

Medical Documentation

Required

S91 (Assign R91)

706 Formula 4-400 gram (14.1 oz) cans powder

9-14.1 oz cans powder

Nutramigen AA LIPIL

Nutramigen AA LIPIL 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

Medical Documentation 707 Formula 1-400 gram (14.1 oz) can powder

Required

Nutramigen AA LIPIL

T91 (Assign R91)

706 Formula 4-400 gram (14.1 oz) cans powder

7-14.1 oz cans powder

Nutramigen AA LIPIL

Nutramigen AA LIPIL S14 Formula 3-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

32-4 oz infant food

N26 Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

3-8 oz infant cereal

foods single ingredient only)

N01 Infant

Medical Documentation

Foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

Cereal: 3-8 oz containers

FP-214

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Pregestimil

Food Package Code

VC Voucher Message

R04

140 Formula 4-16 oz cans powder Pregestimil

7-16 oz cans powder

LIPIL

Pregestimil LIPIL

S08 Formula 3-16 oz cans powder Pregestimil

LIPIL

Medical Documentation

Required

S04 (Assign R04)

140 Formula 4-16 oz cans powder Pregestimil

8-16 oz cans powder

LIPIL

Pregestimil LIPIL

140 Formula 4-16 oz cans powder Pregestimil

LIPIL

Medical Documentation

Required

S08 Formula 3-16 oz cans powder Pregestimil

T04 (Assign R04)

LIPIL

6-16 oz cans powder

S08 Formula 3-16 oz cans powder Pregestimil

Pregestimil LIPIL

LIPIL

N26 Infant

16-4 oz containers baby food fruit

32-4 oz infant food

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

3-8 oz infant cereal

N01 Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

Medical Documentation Required

Infant

foods single ingredient only)

cereal: 3-8 oz containers

FP-215

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Similac PM 60/40

Food Package Code

VC Voucher Message

R14

529 Formula 4-14.1 oz cans powder Similac PM

8-14.1 oz cans powder

60/40

Similac PM 60/40

529 Formula 4-14.1 oz cans powder Similac PM

60/40

Medical Documentation

Required

S14 (Assign R14)

527 Formula 6-14.1 oz cans powder Similac PM

9-14.1 oz cans powder

60/40

Similac PM 60/40

528 Formula 3-14.1 oz cans powder Similac PM

Medical Documentation

60/40

Required

T14 (assign R14)

528 Formula 3-14.1 oz cans powder Similac PM

6-14.1 oz cans powder

60/40

Similac PM 60/40

528 Formula 3-14.1 oz cans powder Similac PM

60/40

32-4 oz infant food

N26 Infant

16-4 oz containers baby food fruit

3-8 oz infant cereal

foods:

and/or vegetable (Stage 2 or 2nd foods single ingredient only)

N01 Infant

Medical Documentation

foods:

Required

16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)

Infant

cereal:

V14 (Assign R14)

529 Formula

7-14.1 oz cans powder

Similac PM 60/40

528 Formula

(special package given at

six months of age for one N01 Infant

month)

foods:

32-4 oz jars infant fruit and vegetables
3-8 oz infant cereal

N26 Infant foods: Infant cereal:

3-8 oz containers 4-14.1 oz cans powder Similac PM 60/40 3-14.1 oz cans powder Similac PM 60/40 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

Medical Documentation Required

FP-216

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Similac Special Care 20

Food Package Code

VC

R10

598

416-2 oz containers ready

to feed Similac Special

Care 20 With Iron

598

Medical Documentation

Required

598

598

522

522

S10 (Assign R10)

598

448-2 oz containers ready

to feed Similac Special

Care 20 With Iron

598

Medical Documentation

Required

598

598

521

522

T10 (Assign R10)

598

320-2 oz containers ready

to feed Similac Special

Care 20 With Iron

598

32-4 oz infant food
598 3-8 oz infant cereal

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 16-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron

FP-217

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Code

VC Voucher Message

Medical Documentation

(2 cases)

Required

522 Formula 16-2 oz containers ready to feed

Similac Special Care 20 With Iron

522 Formula 16-2 oz containers ready to feed

Similac Special Care 20 With Iron

N26 Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

N01 Infant

16-4 oz containers baby food fruit

foods: and/or vegetable (Stage 2 or 2nd

foods single ingredient only)

Infant

cereal: 3-8 oz containers

FP-218

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Similac Special Care 24

Food Package Code

VC

R50

594

416-2 oz containers ready

to feed Similac Special

Care 24 With Iron

594

Medical Documentation

Required

594

594

524

524

S50 (Assign R50)

594

448- 2 oz containers

ready to feed Similac

Special Care 24 With Iron 594

Medical Documentation

Required

594

594

523

524

T50 (Assign R50)

594

320-2 oz containers ready

to feed Similac Special

Care 24 With Iron

594

32-4 oz infant food
594 3-8 oz infant cereal

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 24 With Iron (1 case) Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed

FP-219

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Medical Documentation

Required

524

524

N26

N01

Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

Similac Special Care 24 With Iron (2 cases) 16-2 oz containers ready to feed Similac Special Care 24 With Iron 16-2 oz containers ready to feed Similac Special Care 24 With Iron 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-220

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Similac Special Care 30

Food Package Code

VC

R60

585

416-2 oz containers ready

to feed Similac Special

Care 30 With Iron

585

Medical Documentation

Required

585

585

526

526

S60 (Assign R60)

585

448-2 oz containers ready

to feed Similac Special

Care 30 With Iron

585

Medical Documentation

Required

585

585

525

526

T60 (Assign)

585

320-2 oz containers ready

to feed Similac Special

Care 30 With Iron

585

32-4 oz infant food
585 3-8 oz infant cereal

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 30 With Iron (1 case) Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed

FP-221

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Medical Documentation

Required

526

526

N26

N01

Formula
Formula
Infant foods:
Infant foods: Infant cereal:

Similac Special Care 30 With Iron (2 cases) 16-2 oz containers ready to feed Similac Special Care 30 With Iron 16-2 oz containers ready to feed Similac Special Care 30 With Iron 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only) 16-4 oz containers baby food fruit and/or vegetable (Stage 2 or 2nd foods single ingredient only)
3-8 oz containers

FP-222

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17

Non-Contract Special Infant Formulas for Children

Alimentum
Food Package Code X01 8-1 lb cans powder Alimentum

VC Voucher Message 360 Formula 4-1 lb cans powder Alimentum 360 Formula 4-1 lb cans powder Alimentum

Medical Documentation

Required

X03

150

28-32 oz containers ready

to feed Alimentum

150

Medical Documentation Required

Formula Formula

14-32 oz containers ready to feed Alimentum 14-32 oz containers ready to feed Alimentum

EleCare
Food Package Code X89 9-14.1 oz cans powder EleCare

VC Voucher Message 532 Formula 6-14.1 oz cans powder EleCare (1
case) 533 Formula 3-14.1 oz cans powder EleCare

Medical Documentation Required

EnfaCare LIPIL

Food Package Code

VC

X78

541

11-12.8 oz cans powder

Enfamil EnfaCare LIPIL S11

X79

543

28-32 oz containers ready

to feed Enfamil EnfaCare 543 LIPIL

543 No Child Packages were

created in the Database 543

S12

Voucher Message Formula 6-12.8 oz cans powder Enfamil
EnfaCare LIPIL (1 case) Formula 5-12.8 oz cans powder Enfamil
EnfaCare LIPIL Formula 6-32 oz containers ready to feed
Enfamil EnfaCare LIPIL (1 case) Formula 6-32 oz containers ready to feed
Enfamil EnfaCare LIPIL (1 case) Formula 6-32 oz containers ready to feed
Enfamil EnfaCare LIPIL (1 case) Formula 6-32 oz containers ready to feed
Enfamil EnfaCare LIPIL (1 case) Formula 4-32 oz containers ready to feed
Enfamil EnfaCare LIPIL

FP-223

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Similac NeoSure

Food Package Code

VC

X92

519

1012.8 oz cans powder

Similac NeoSure

520

Medical Documentation

Required

X73

517

28-32 oz containers ready

to feed Similac NeoSure 517

Medical Documentation Required

517

517

S09

Voucher Message Formula 6-12.8 oz cans powder Similac
NeoSure (1 case) Formula 4-12.8 oz cans powder Similac
NeoSure

Formula Formula Formula Formula Formula

6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case) 6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case) 4-32 oz containers ready to feed Similac NeoSure

Nutramigen LIPIL Food Package Code X81 10-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

VC Voucher Message 156 Formula 5-12.6 oz cans powder Nutramigen
LIPIL with Enflora LGG 156 Formula 5-12.6 oz cans powder Nutramigen
LIPIL with Enflora LGG

Medical Documentation

Required

X82

N67

35-13 oz cans concentrate

Nutramigen LIPIL

N57

Medical Documentation

Required

X83

S03

28-32 oz containers ready

to feed Nutramigen

S03

LIPIL

Formula Formula
Formula Formula

16-13 oz cans concentrate Nutramigen LIPIL 19-13 oz cans concentrate Nutramigen LIPIL
14-32 oz containers ready to feed Nutramigen LIPIL 14-32 oz containers ready to feed Nutramigen LIPIL

Medical Documentation Required

FP-224

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Pregestimil

Food Package Code

VC

X04

140

8-1 lb cans powder

Pregestimil LIPIL

140

Medical Documentation Required

Voucher Message Formula 4-1 lb cans powder Pregestimil
LIPIL Formula 4-1 lb cans powder Pregestimil
LIPIL

Portagen Food Package Code X20 13-1 lb cans powder Portagen

VC Voucher Message 060 Formula 4-1 lb cans powder Portagen 060 Formula 4-1 lb cans powder Portagen 260 Formula 5-1 lb cans powder Portagen

Medical Documentation Required

Similac PM 60/40

Food Package Code

VC

X14

529

8-14.1 oz cans powder

Similac PM 60/40

529

Medical Documentation Required

Voucher Message Formula 4-14.1 oz cans powder Similac PM
60/40 Formula 4-14.1 oz cans powder Similac PM
60/40

FP-225

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Non-Contract Special Formulas for Children

Bright Beginnings Soy Pediatric Drink

Food Package Code

VC Voucher Message

X86

330 Formula 30-8 oz containers ready to feed

30-8 oz containers ready

Bright Beginnings Soy Pediatric

to feed Bright Beginnings

Drink

Soy Pediatric Drink

Medical Documentation

Required

X34

330

60-8 oz containers ready

to feed Bright Beginnings

Soy Pediatric Drink

330

Medical Documentation Required

X35

330

90-8 oz containers ready

to feed Bright Beginnings

Soy Pediatric Drink

330

Medical Documentation

Required

330

X36

330

108-8 oz containers ready

to feed Bright Beginnings

Soy Pediatric Drink

330

Medical Documentation

Required

330

118

Formula

30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink

Formula

30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink

Formula Formula Formula Formula Formula Formula Formula

30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink 18-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink

FP-226

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

EO28 Splash

Food Package Code

VC

X51

513

31-237 ml containers

ready to feed EO28

Splash

514

Medical Documentation

required

X52

513

62-237 ml containers ready to feed EO28

513

Splash

514

Medical Documentation

Required

514

X53

513

112-237 ml containers

ready to feed EO28

513

Splash

513

Medical Documentation 513 Required
514

Voucher Message Formula 27-237 ml containers ready to feed
EO28 Splash (1 case)
Formula 4-237 ml containers ready to feed EO28 Splash (1-4 pack)

Formula Formula Formula Formula Formula Formula Formula Formula Formula

27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 4-237 ml containers ready to feed EO28 Splash (1-4 pack) 4-237 ml containers ready to feed EO28 Splash (1-4 pack) 27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 4-237 ml containers ready to feed EO28 Splash (one 4-pack)

Neocate Junior

Food Package Code

VC

X75

508

14-400 gram (14.1 oz)

cans powder Neocate

508

Junior

Medical Documentation 508

required

509

Voucher Message Formula 4-400 gram (14.1 oz) cans powder
Neocate Junior

Formula Formula Formula

4-400 gram (14.1 oz) cans powder Neocate Junior 4-400 gram (14.1 oz) cans powder Neocate Junior 2-400 gram (14.1 oz) cans powder Neocate Junior

FP-227

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Neocate One+

Food Package Code

VC

X72

510

30-60 gram packets

powder

Neocate One+

510

Medical Documentation

required

X77

510

60-60 gram packets

powder

510

Neocate One+

510 Medical Documentation

Required

510

X74

510

113-60 gram packets

powder Neocate One+ 510

Medical Documentation 510 Required
510

510

510

510

581

Voucher Message Formula 15-60 gram packets powder
Neocate One+ (1 case)
Formula 15-60 gram packets powder Neocate One+ (1 case)

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

15-60 gram packets powder Neocate One+ (1 case)
15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 15-60 gram packets powder Neocate One+ (1 case) 8-60 gram packets powder Neocate One+

FP-228

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Nutren Junior

Food Package Code

VC

X57

559

35-250 ml containers

ready to feed Nutren

Junior

560

Medical Documentation

required

X58

559

59-250 ml containers

ready to feed Nutren

559

Junior

560 Medical Documentation

Required

X59

559

107-250 ml containers

ready to feed Nutren

559

Junior

559

Medical Documentation

Required

559

560

Voucher Message Formula 24-250 ml containers ready to feed
Nutren Junior (1 case)
Formula 11-250 ml containers ready to feed Nutren Junior

Formula Formula Formula

24-250 ml containers ready to feed Nutren Junior (1 case)
24-250 ml containers ready to feed Nutren Junior (1 case) 11-250 ml containers ready to feed Nutren Junior

Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Nutren Junior (1 case) 24-250 ml containers ready to feed Nutren Junior (1 case) 24-250 ml containers ready to feed Nutren Junior (1 case) 24-250 ml containers ready to feed Nutren Junior (1 case) 11-250 ml containers ready to feed Nutren Junior

FP-229

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Nutren Junior Fiber

Food Package Code

VC

X60

561

35-250 ml containers

ready to feed Nutren

Junior Fiber

562

Medical Documentation

required

X37

561

59-250 ml containers

ready to feed Nutren

561

Junior Fiber

562 Medical Documentation

Required

X62

561

107-250 ml containers

ready to feed Nutren

561

Junior Fiber

561 Medical Documentation

Required

561

562

Voucher Message Formula 24-250 ml containers ready to feed
Nutren Junior Fiber (1 case)
Formula 11-250 ml containers ready to feed Nutren Junior Fiber

Formula Formula Formula

24-250 ml containers ready to feed Nutren Junior Fiber (1 case) 24-250 ml containers ready to feed Nutren Junior Fiber (1 case) 11-250 ml containers ready to feed Nutren Junior Fiber

Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Nutren Junior Fiber (1 case) 24-250 ml containers ready to feed Nutren Junior Fiber (1 case) 24-250 ml containers ready to feed Nutren Junior Fiber (1 case) 24-250 ml containers ready to feed Nutren Junior Fiber (1 case) 11-250 ml containers ready to feed Nutren Junior Fiber

FP-230

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

PediaSure

Food Package Code

VC Voucher Message

X84

730 Formula 30-8 oz containers ready to feed

30-8 oz containers ready

PediaSure

to feed PediaSure

Medical Documentation

required

X30

730

60-8 oz containers ready

to feed PediaSure

730

Medical Documentation

Required

X87

730

90-8 oz containers ready

to feed PediaSure

730

Medical Documentation 730 Required

X88

730

108-8 oz containers ready

to feed PediaSure

730

Medical Documentation 730 Required
718

Formula Formula

30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure

Formula Formula Formula Formula Formula Formula Formula

30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 18-8 oz containers ready to feed PediaSure (three 6-packs)

FP-231

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

PediaSure with Fiber

Food Package Code

VC Voucher Message

X76

731 Formula 30-8 oz containers ready to feed

30-8 oz containers ready

PediaSure With Fiber

to feed PediaSure With

Fiber

Medical Documentation

required

X85

731

60-8 oz containers ready

to feed PediaSure With 731

Fiber

Formula Formula

30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber

Medical Documentation

Required

X78

731

90-8 oz containers ready

to feed PediaSure With 731 Fiber

731 Medical Documentation

Required

X79

731

108-8 oz containers ready

to feed PediaSure With 731 Fiber

731 Medical Documentation

Required

719

Formula Formula Formula

30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber

Formula Formula Formula Formula

30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber 18-8 oz containers ready to feed PediaSure With Fiber (three 6-packs)

FP-232

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Peptamen Junior

Food Package Code

VC

X66

571

35-250 ml containers

ready to feed Peptamen

Junior

572

Medical Documentation

required

X67

571

59-250 ml containers

ready to feed Peptamen 571 Junior

572 Medical Documentation

Required

X68

571

107-250 ml containers

ready to feed Peptamen 571

Junior

571

Medical Documentation

Required

571

572

Voucher Message Formula 24-250 ml containers ready to feed
Peptamen Junior (1 case)
Formula 11-250 ml containers ready to feed Peptamen Junior

Formula Formula Formula

24-250 ml containers ready to feed Peptamen Junior (1 case)
24-250 ml containers ready to feed Peptamen Junior (1 case) 11-250 ml containers ready to feed Peptamen Junior

Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Peptamen Junior (1 case) 24-250 ml containers ready to feed Peptamen Junior (1 case) 24-250 ml containers ready to feed Peptamen Junior (1 case) 24-250 ml containers ready to feed Peptamen Junior (1 case) 11-250 ml containers ready to feed Peptamen Junior

FP-233

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

Peptamen Junior with Prebio

Food Package Code

VC

X69

576

35-250 ml containers

ready to feed Peptamen

Junior with Prebio

577

Medical Documentation

required

X70

576

59-250 ml containers

ready to feed Peptamen Junior with Prebio

576

Medical Documentation Required

577

X05

576

107-250 ml containers

ready to feed Peptamen

Junior with Prebio

576

Medical Documentation

Required

576

576

577

Voucher Message Formula 24-250 ml containers ready to feed
Peptamen Junior with Prebio (1 case) Formula 11-250 ml containers ready to feed Peptamen Junior with Prebio

Formula Formula Formula Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 11-250 ml containers ready to feed Peptamen with Prebio 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 11-250 ml containers ready to feed Peptamen Junior with Prebio

FP-234

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-18

Non-Contract Special Formulas for Women

Boost

Food Package Code

VC

X39

555

30-8 oz containers ready

to feed Boost 554

Medical Documentation required
555

X40 60-8 oz containers ready 555 to feed Boost

554

Medical Documentation

Required

554

X02

555

90-8 oz containers ready

to feed Boost

555

Medical Documentation 555 Required
554

554

554

X42

555

112-8 oz containers ready

to feed Boost

555

Medical Documentation 555 Required
555

556

Voucher Message Formula 24-8 oz containers ready to feed
Boost (1 case)
Formula 6-8 oz containers ready to feed Boost (one 6-pack)

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 6-8 oz containers ready to feed Boost (one 6-pack) 6-8 oz containers ready to feed Boost (one 6-pack) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 6-8 oz containers ready to feed Boost (one 6-pack) 6-8 oz containers ready to feed Boost (one 6-pack) 6-8 oz containers ready to feed Boost (one 6-pack) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 16-8 oz containers ready to feed Boost

FP-235

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Ensure

Food Package Code

VC

X06

537

30-8 oz containers ready

to feed Ensure 302

Medical Documentation required

X38

537

60-8 oz containers ready

to feed Ensure

537

Medical Documentation 538 Required

X45

537

90-8 oz containers ready

to feed Ensure

537

Medical Documentation 537 Required
538

302

X15

537

108-8 oz containers ready

to feed Ensure

537

Medical Documentation 537 Required
537

538

Voucher Message Formula 24-8 oz containers ready to feed
Ensure (1 case)
Formula 6-8 oz containers ready to feed Ensure (one 6-pack)

Formula Formula Formula
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 12-8 oz containers ready to feed Ensure (two 6-pack)
24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 12-8 oz containers ready to feed Ensure (2-6 pack) 6-8 oz containers ready to feed Ensure (one 6-pack) 24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 12-8 oz containers ready to feed Ensure (two 6-pack)

FP-236

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Ensure Fiber

Food Package Code

VC

X47

579

30-8 oz containers ready

to feed Ensure Fiber 304

Medical Documentation Required

X48

579

60-8 oz containers ready

to feed Ensure Fiber

579

Medical Documentation 580 Required

X49

579

90-8 oz containers ready

to feed Ensure Fiber

579

Medical Documentation 579 Required
580

304

X50

579

108-8 oz containers ready

to feed Ensure Fiber

579

Medical Documentation 579 Required
579

580

Voucher Message Formula 24-8 oz containers ready to feed
Ensure Fiber (1 case)
Formula 6-8 oz containers ready to feed Ensure Fiber (one 6-pack)

Formula Formula Formula
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 12-8 oz containers ready to feed Ensure Fiber (two 6-pack)
24-8 oz containers ready to feed Ensure (Fiber 1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 12-8 oz containers ready to feed Ensure Fiber (two 6-pack) 6-8 oz containers ready to feed Ensure Fiber (one 6-pack) 24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 12-8 oz containers ready to feed Ensure Fiber (two 6-pack)

FP-237

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Nutren 2.0

Food Package Code

VC

X54

567

35-250 ml containers

ready to feed Nutren 2.0 568

Medical Documentation required

X55

567

59-250 ml containers

ready to feed Nutren 2.0 567

Medical Documentation 568 Required

X56

567

107-250 ml containers

ready to feed Nutren 2.0 567

Medical Documentation 567 Required
567

568

Voucher Message Formula 24-250 ml containers ready to feed
Nutren 2.0 (1 case)
Formula 11-250 ml containers ready to feed Nutren 2.0

Formula Formula Formula Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Nutren 2.0 (1 case)
24-250 ml containers ready to feed Nutren 2.0 (1 case) 11-250 ml containers ready to feed Nutren 2.0 24-250 ml containers ready to feed Nutren 2.0 (1 case) 24-250 ml containers ready to feed Nutren 2.0 (1 case) 24-250 ml containers ready to feed Nutren 2.0 (1 case) 24-250 ml containers ready to feed Nutren 2.0 (1 case) 11-250 ml containers ready to feed Nutren 2.0

FP-238

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Peptamen

Food Package Code

VC

X63

569

35-250 ml containers

ready to feed Peptamen 570

Medical Documentation required

X64

569

59-250 ml containers

ready to feed Peptamen 569

Medical Documentation 570 Required

X65

569

107-250 ml containers

ready to feed Peptamen 569

Medical Documentation 569 Required
569

570

Voucher Message Formula 24-250 ml containers ready to feed
Peptamen (1 case)
Formula 11-250 ml containers ready to feed Peptamen

Formula Formula Formula Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Peptamen (1 case)
24-250 ml containers ready to feed Peptamen (1 case) 11-250 ml containers ready to feed Peptamen 24-250 ml containers ready to feed Peptamen (1 case) 24-250 ml containers ready to feed Peptamen (1 case) 24-250 ml containers ready to feed Peptamen (1 case) 24-250 ml containers ready to feed Peptamen (1 case) 11-250 ml containers ready to feed Peptamen

FP-239

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-19

Tracking Vouchers Can be Given to Women, Children or Infants

Emory Genetics

Food Package Code

VC Voucher Message

099

099 Formula This voucher has no cash value

Grocers should not accept this

Medical Documentation

voucher

Required

Client copy: Formula Provided by

Emory Genetics.

Emory Genetics 404-778-8519

Georgia WIC 800-228-9173

299

This voucher has no cash value.

Grocers should not accept this

voucher

Emory Genetics Copy:

Formula provided by Emory

Genetics

Fax to Emory Genetics: 404-778-8562

Formula Name: _______ Cost:

________

399

This voucher has no cash value

Grocers should not accept this

voucher

Chart Copy / File in participants

health record:

Formula provided by Emory

Genetics

Contact Information:

Emory Genetics- 404-778-8519 /

Georgia WIC- 800-228-9173

FP-240

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Formula Provided from Stock on Hand

Food Package Code

VC Voucher Message

197

197 Formula This voucher has no cash value

Grocers should not accept this

voucher

Formula provided from stock on hand. Document formula quantity and type issued in client's medical record and Formula Tracking Log

Formula Ordered from Nutrition Section

Food Package Code

VC Voucher Message

199

199 Formula This voucher has no cash value

Grocers should not accept this

voucher

Formula ordered from the Office of

Nutrition

Document formula quantity and

type issued in client's medical

record and Formula Tracking Log

FP-241

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20

Special Formula Packages for Infants Age 6-11 Months Unable to Eat Solid Foods

Alimentum Food Package Code
S01 (Assign S01) 8-16 oz cans powder Alimentum

VC Voucher Food Package Number Message
360 Formula 4-16 oz cans powder Alimentum
360 Formula 4-16 oz cans powder Alimentum

Medical Documentation

Required

S03 (Assign S03)

150

28-32 oz containers ready

to feed Alimentum

150

Medical Documentation Required

Formula Formula

14-32 oz containers ready to feed Alimentum 14-32 oz containers ready to feed Alimentum

EleCare Food Package Code
S11 (Assign S11) 10-14.1 oz cans powder EleCare

VC Voucher Food Package Number Message
532 Formula 6-14.1 oz cans powder EleCare (1 case)
534 Formula 4-14.1 oz cans powder EleCare

Medical Documentation Required

EleCare with DHA and ARA

Food Package Code

VC

S41 (Assign S41)

S33

10-14.1 oz cans powder

EleCare with DHA and S35

ARA

Voucher Message Formula
Formula

Food Package Number
6-14.1 oz cans powder EleCare with DHA and ARA (1 case) 4-14.1 oz cans powder EleCare with DHA and ARA

Medical Documentation Required

FP-242

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

EnfaCare LIPIL

Food Package Code

VC

S24 (Assign S24)

541

11-12.8 oz cans powder

Enfamil EnfaCare LIPIL S11

Medical Documentation

Required

S26 (Assign S26)

543

28-32 oz containers ready

to feed Enfamil EnfaCare 543

LIPIL

543 Medical Documentation

Required

543

S12

S20 (Assign S20)

589

444-2 oz containers ready

to feed Enfamil EnfaCare 589 LIPIL

589 Medical Documentation

Required

589

539

S20

Voucher Message Formula
Formula

Food Package Number
6-12.8 oz cans powder Enfamil EnfaCare LIPIL 5-12.8 oz cans powder Enfamil EnfaCare LIPIL

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 4-32 oz containers ready to feed Enfamil EnfaCare LIPIL 96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare LIPIL (2 case) 48-2 oz containers ready to feed Enfamil EnfaCare LIPIL (1 case) 12-2 oz containers ready to feed Enfamil EnfaCare LIPIL

FP-243

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Enfamil Premature LIPIL 20

Food Package Code

VC

S30 (Assign S30)

595

444-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL 595

20

595 Medical Documentation Required
595

545

S21

Voucher Message Formula
Formula
Formula
Formula
Formula
Formula

Food Package Number
96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL20 (2 cases) 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (1 case) 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

Enfamil Premature LIPIL 24

Food Package Code

VC

S40 (Assign S40)

597

444-2 oz containers ready

to feed Enfamil

Premature LIPIL 24

597

Medical Documentation 597 Required
597

547

Voucher Message Formula
Formula
Formula
Formula
Formula

Food Package Number
96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (1 case)

FP-244

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

S22 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24

Neocate Infant

Food Package Code

VC

S51 (Assign S51)

506

11-400 gram (14.1 oz)

cans powder Neocate

506

Infant

507 Medical Documentation

Required

507

507

Voucher Message Formula
Formula
Formula
Formula
Formula

Food Package Number
4-400 gram (14.1 oz) cans powder Neocate Infant 4-400 gram (14.1 oz) cans powder Neocate Infant 1-400 gram (14.1 oz) can powder Neocate Infant 1-400 gram (14.1 oz) can powder Neocate Infant 1-400 gram (14.1 oz) can powder Neocate Infant

FP-245

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Neocate Infant DHA & ARA

Food Package Code

VC

S61 (Assign S61)

500

11-400 gram (14.1 oz)

500

cans powder Neocate

Infant DHA & ARA

505

Medical Documentation 505 Required
505

Voucher Message Formula
Formula
Formula
Formula
Formula

Food Package Number
4-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA 4-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA 1-400 gram (14.1 oz) can powder Neocate Infant DHA & ARA 1-400 gram (14.1 oz) can powder Neocate Infant DHA & ARA 1-400 gram (14.1 oz) can powder Neocate Infant DHA & ARA

FP-246

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

NeoSure

Food Package Code

VC

S71 (Assign S71)

519

11-12.8 oz cans powder

Similac NeoSure

S25

Medical Documentation

Required

S73 (Assign S73)

517

28-32 oz containers ready

to feed Similac NeoSure 517

517

Medical Documentation

Required

517

S09

S70 (Assign S70)

596

448-2 oz containers ready

to feed Similac NeoSure 596

Medical Documentation 596 Required
596

515

516

Voucher Message Formula
Formula

Food Package Number
6-12.8 oz cans powder Similac NeoSure (1 case) 5-12.8 oz cans powder Similac NeoSure

Formula Formula Formula Formula
Formula Formula Formula Formula Formula Formula Formula

6-32 oz containers ready to feed Similac NeoSure (1 case) 6-32 oz containers ready to feed Similac NeoSure (1 case) 6-32 oz containers ready to feed Similac NeoSure (1 case)
6-32 oz containers ready to feed Similac NeoSure (1 case) 4-32 oz containers ready to feed Similac NeoSure 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 96-2 oz containers ready to feed Similac NeoSure (2 cases) 48-2 oz containers ready to feed Similac NeoSure (1 case) 16-2 oz containers ready to feed Similac NeoSure

FP-247

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Nutramigen LIPIL

Food Package Code

VC

S82 (Assign S82)

N08

34-13 oz cans concentrate N57 Nutramigen LIPIL

Voucher Message Formula
Formula

Food Package Number
15-13 oz cans concentrate Nutramigen LIPIL 19-13 oz cans concentrate Nutramigen LIPIL

Medical Documentation

Required

S81 (Assign S81)

156

11-12.6 oz cans powder

Nutramigen LIPIL with 155

Enflora LGG

Medical Documentation Required

S83 (Assign S83)

S03

28-32 oz containers ready

to feed Nutramigen

S03

LIPIL

Formula Formula
Formula Formula

5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 6-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG
14-32 oz containers ready to feed Nutramigen LIPIL 14-32 oz containers ready to feed Nutramigen LIPIL

Medical Documentation Required

Nutramigen AA LIPIL

Food Package Code

VC

S91 (Assign S91)

706

9-14.1 oz cans powder

Nutramigen AA LIPIL 706

Medical Documentation 707 Required

Voucher Message Formula
Formula
Formula

Food Package Number
4-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 4-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 1-400 gram (14.1 oz) can powder Nutramigen AA LIPIL

FP-248

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Pregestimil LIPIL

Food Package Code

VC

S04 (Assign S04)

140

8-16 oz cans powder

Pregestimil LIPIL

140

Medical Documentation Required

Voucher Message Formula
Formula

Food Package Number
4-16 oz cans powder Pregestimil LIPIL 4-16 oz cans powder Pregestimil LIPIL

Similac PM 60/40

Food Package Code

VC

S14 (assign S14)

527

9-14.1 oz cans powder

Similac PM 60/40

Medical Documentation 528 Required

Voucher Message Formula
Formula

Food Package Number
6-14.1 oz cans powder Similac PM 60/40 (1 case) 3-14.1 oz cans powder Similac PM 60/40

Similac Special Care 20

Food Package Code

VC

S10 (Assign S10)

598

448-2 oz containers ready

to feed Similac Special

Care 20 With Iron

598

Medical Documentation

Required

598

598

521

522

Voucher Message Formula
Formula
Formula
Formula
Formula
Formula

Food Package Number
96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 48-2 oz containers ready to feed Similac Special Care 20 With Iron (1 case) 16-2 oz containers ready to feed Similac Special Care 20 With Iron

FP-249

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Similac Special Care 24

Food Package Code

VC

S50 (Assign S50)

594

448- 2 oz containers

ready to feed Similac

Special Care 24 With Iron 594

Medical Documentation

Required

594

594

523

524

Voucher Message Formula
Formula
Formula
Formula
Formula
Formula

Food Package Number
96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) 48-2 oz containers ready to feed Similac Special Care 24 With Iron (1 case) 16-2 oz containers ready to feed Similac Special Care 24 With Iron

Similac Special Care 30

Food Package Code

VC

S60 (Assign S60)

585

448-2 oz containers ready

to feed Similac Special

Care 30 With Iron

585

Medical Documentation

Required

585

585

525

526

Voucher Message Formula
Formula
Formula
Formula
Formula
Formula

Food Package Number
96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) 48-2 oz containers ready to feed Similac Special Care 30 With Iron (1 case) 16-2 oz containers ready to feed Similac Special Care 30 With Iron

FP-250

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-21

INFANT FOOD PACKAGES - MAXIMUM MONTHLY AMOUNTS AUTHORIZED
A. FORMULA TYPES, SIZES, AND MAXIMUM AMOUNTS
(1) Fully Formula Fed (FFF) Infant

FFF: Table for Concentrate Formula

TYPE1

Container

MAXIMUM AMOUNTS3 (By Infant Age)

SIZE2

Age 0-3 Months

Age 4-5 Months Age 6-11 Months

Concentrate

13 ounces

31 cans or

34 cans or

24 cans or

Maximum listed in reconstituted fluid ounces

403 oz concentrate or 806 oz reconstituted or 26.9 oz per day

264 oz concentrate or 884 oz reconstituted or 29.5 oz per day

312 oz concentrate or 624 oz reconstituted or 20.8 oz per day

Maximum Allowed

806 fl oz

884 fl oz

624 fl oz

FFF: Table for Ready-To-Feed Formula

TYPE1

Container

MAXIMUM AMOUNTS3 (By Infant Age)

SIZE2

Age 0-3 Months

Age 4-5 Months Age 6-11 Months

Ready-To-Feed 32 ounces

26 cans

28 cans

20 cans

2 ounces

416 bottles

448 bottles

320 bottles

3 ounces

277 bottles

298 bottles

213 bottles

4 ounces

208 bottles

224 bottles

160 bottles

8 ounces

104 cans

112 cans

80 cans

Maximum Allowed

832 fl oz

896 fl oz

640 fl oz

1 For each type listed, the most economical size is recommended. 2 Sizes listed are not all-inclusive. 3 Maximum amounts are listed for each age group for each form.

FP-251

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

FFF: Table for Powder Formulas with Standard Mixing Instructions4

TYPE1

MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder)

Powdered4 Reconstituted fluid ounces per container

Age 0-2 months

Age 3 months

Age 4-5 months

Age

Age

6 months 7-11 months

82-87

10

10

11

8

8

90-96

9

9

10

7

7

98-99

8

9

9

7

7

101-103

8

8

9

7

6

111-115

7

8

8

6

6

Maximum Allowed

870 fl oz

870 fl oz

960 fl oz

696 fl oz 696 fl oz

4 Formula yield per container based on standard mixing instructions (reconstituted). Refer to product label or manufacturer's website for reconstitution. If fluid ounce yield is not listed on label ask for assistance from Office of Nutrition.

FFF: Table for Exempt Infant Formula and Medical Foods Without Standard

Reconstitution Instructions

TYPE1 Container MAXIMUM AMOUNTS5 (By Infant Age in # of Cans of Powder)

SIZE2

Powdered5

Age 0-3 Months (128 oz Age 4-5 Months (141 oz Age 6-11 Months (102 oz maximum by can weight) maximum by can weight) maximum by can weight)

12 ounces

10 cans (120 oz)

11 cans

8 cans

12.8 ounces 10 cans- (128 oz)

11 cans

7 cans

12.9 ounces 9 cans- (116.1 oz)

10 cans

7 cans

14.1 ounces 9 cans- (126.9 oz)

10 cans

7 cans

14.3 ounces 8 cans- (114.4 oz)

9 cans

7 cans

16 ounces

8 cans- (128 oz)

8 cans

6 cans

24 ounces

5 cans- (120 oz)

5 cans

4 cans

25.7 ounces 4 cans- (102.8 oz)

5 cans

3 cans

Exempt infant formulas are those designed for low birth weight infants or infants with an inborn error of metabolism, or other medical or nutritional problem. To determine if a formula is exempt visit the WIC formula database at:
http://grande.nal.usda.gov/wicworks/formulas/FormulaSearch.php .
Each formula is categorized as an infant formula or an exempt infant formula.
5 Use this table only for exempt infant formulas and medical foods that do not have standard instructions for reconstitution, such as metabolic formulas.

FP-252

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-22

(2) Mostly Breastfed (MBF) Infant

MBF: Table for Concentrate Formula

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age)

SIZE2

Age 0-1 Month Age 1-3 Months Age 4-5 Months Age 6-11 Months

Concentrate 13 ounces
Maximum listed in reconstituted fluid ounces

4 cans or

14 cans or

17 cans or

52 oz concentrate or 182 oz concentrate 221 oz concentrate

104 oz reconstituted 364 oz reconstituted 442 oz reconstituted

3.5 oz per day

12 oz per day

14.5 oz per day

12 cans or 156 oz concentrate 312 oz reconstituted 10.4 oz per day

Max. oz

104 fl oz

364 fl oz

442 fl oz

312 fl oz

MBF: Table for Ready-To-Feed Formula

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder) SIZE2

Age 0-1 Month Age 1-3 Months Age 4-5 Months Age 6-11 Months

Ready-To-Feed 32 ounces 3 cans

12 cans

14 cans

10 cans

2 ounces 52 bottles

192 bottles

224 bottles

160 bottles

3 ounces 34 bottles

128 bottles

149 bottles

106 bottles

4 ounces 26 bottles

96 bottles

112 bottles

80 bottles

8 ounces 13 cans

48 cans

56 cans

40 cans

Max. oz

104 fl oz

384 fl oz

448 fl oz

320 fl oz

1 For each type listed, the most economical size is recommended. 2 Sizes listed are not inclusive. 3 Maximum amounts are listed for each type.

FP-253

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-22 (cont'd)

MBF: Table for Powder Formulas with Standard Mixing Instructions

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder) SIZE2

Powdered4

Reconstituted fluid ounces per container

Age 0-1 Month

Age 1-2 Months

Age 3 Months

Age 4-5 Months

Age 6-11 Months

82-87

1

5

5

6

4

90-96

1

4

4

5

4

98-99

1

4

4

5

3

101-103

1

4

4

5

3

111-115

1

3

4

4

3

Max oz

104 fl oz

435 fl oz

435 fl oz

522 fl oz

384 fl oz

4 Formula yield per container based on standard mixing instructions (reconstituted). Refer to product label or manufacturer's website for reconstitution. If fluid ounce yield is not listed on label ask for assistance from Office of Nutrition.

MBF: Table for Exempt Infant Formula and Medical Foods Without Standard

Reconstitution Instructions

TYPE1 Container MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder)

SIZE2

Powdered5

Age 0-3 Months (64 oz

4-5 months (77 oz maximum 6-11 months (56 oz

maximum by can weight) by can weight)

maximum by can weight)

12 ounces 5 cans (60 oz)

6 cans

4 cans

12.8 ounces 5 cans- (64 oz)

5 cans

4 cans

12.9 ounces 4 cans- (51.6 oz)

5 cans

4 cans

14.1 ounces 4 cans- (56.4 oz)

5 cans

3 cans

14.3 ounces 4 cans- (57.2 oz)

5 cans

3 cans

16 ounces 4 cans- (64 oz)

4 cans

3 cans

24 ounces 2 cans- (48 oz)

3 cans

2 cans

25.7 ounces 2 cans- (51.4 oz)

2 cans

2 cans

Exempt infant formulas are those designed for low birth weight infants or infants with an inborn error of metabolism, or other medical or nutritional problem. To determine if a formula is exempt visit the WIC formula database at:
http://grande.nal.usda.gov/wicworks/formulas/FormulaSearch.php .
Each formula is categorized as an infant formula or an exempt infant formula.
5 Use this table only for powdered products that do not have standard instructions for reconstitution, such as metabolic formulas.

FP-254

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-23

B. INFANT FOODS MAXIMUM MONTHLY AMOUNTS (For Infants 6 through 11 Months)

INFANT FOOD

SIZE

MAXIMUM AMOUNTS

FFF MBF

Exclusively Breastfed

Infant Cereal

8 ounces

24 oz

24 oz

Infant Fruit and Vegetable

4 ounces

128 oz (32 jars)

256 oz (64 jars)

Infant Meats

2.5 ounces

N/A

77.5 oz (31 jars)

FP-255

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-24

SUPPLEMENTAL FORMULA CONVERSION TABLE
Displacement Method for Modular Products

Monthly RX

Concentrate13 oz

*Duocal (14.1 oz powder)

1 can

4

2 cans

8

3 cans

12

4 cans

16

** Polycose (12.3 oz powder)

1 can

4

2 cans

8

3 cans

12

4 cans

16

*** MCT Oil (32 fl oz bottle)

1 bottle

3

2 bottles

6

Amount of Formula Replaced

Powder12 - 16 oz

Powder22- 24 oz

Ready-to-Feed 32 oz

1

1

4

2

1

7

3

2

10

4

2

13

1

1

4

2

1

7

3

2

10

4

2

13

1

1

3

2

1

3

*

Duocal powder: 1 can contains 42 TBSP/1968 Calories

**

Polycose powder: 1 can contains 59 TBSP/1330 Calories

***

MCT Oil: 1 bottle contains 960 cc/64 TBSP/7392 Calories

3 teaspoons = 1 TBSP 1 fl oz = 30 cc

FP-256

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-25

CHILDREN & WOMEN WITH QUALIFYING MEDICAL CONDITIONS FOOD PACKAGE III: MAXIMUM MONTHLY AMOUNTS AUTHORIZED See Also Children and Women Maximum Amounts Attachment FP-26 & FP-27

A. FORMULA TYPES, SIZES AND ADDITIONAL AMOUNTS

Formula Type: Child Max

Concentrate- 455 fluid ounces

RTF-

910 fluid ounces

Powder-

910 fluid ounces reconstituted or 144 oz (if no standard dilution)

TYPE Concentrate
Ready-To-Feed

CAN SIZE 13 ounces
32 ounces

Children & Women Maximum Amounts 35 cans or 455 ounces maximum concentrate or 910 fluid ounces reconstituted 28 cans or 910 fluid ounces

Table for Powder Formulas With Standard Mixing Instructions

Powdered4

Reconstituted fluid ounces per Maximum Number of Cans Allowed

container

66-70

13

71-75

12

76-82

11

83-91

10

92-101

9

102-113

8

114-130

7

Maximum Allowed

910 fl oz

4 Refer to product label or manufacturer's website for reconstitution.

Table for Powder Exempt Infant Formulas and Medical Foods Without Standard

Reconstitution Instructions for Children and Women

Powdered5

144 ounces Maximum by can Maximum Number of Cans Allowed Per

weight

Month

12 ounces

12 cans

12.8 ounces

11 cans

12.9 ounces

11 cans

14.1 ounces

10 cans

14.3 ounces

10 cans

16 ounces

9 cans

24 ounces

6 cans

25.7 ounces

5 cans

5 Use this table only for powdered products that do not have standard instructions for reconstitution, such as metabolic formulas.

FP-257

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-26

CHILDREN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED FOR CHILDREN

FOOD

Food Package IV MAXIMUM AMOUNT PER MONTH

Milk1

16 quart equivalents2

Cheese Tofu

4 pounds3 8 pounds8

Eggs

1 dozen

Juice

2-64 ounce containers

Cereal
Beans/Peas OR Peanut Butter Fruits and Vegetables

36 ounces
1 pound bag dried or 4 cans (14-16 ounces) OR 1 container (16-18 oz)
$6.00

Whole Grain Bread or alternative

32 ounces

1 May substitute up to 16 quarts of lactose reduced milk for up to 4 gallons of milk.

2 Substitution amounts for fluid milk include: ITEM

FLUID MILK EQUIVALENTS

Cheese, 1 pound

3 quarts3

Evaporated milk, whole or skim , 12 ounces

4 cans equal 3 quarts4,5

Nonfat or low-fat dry milk

1-3 quart box equal to 3 quarts6,7

Tofu, 1 pound

1 quart8

3 Subtract from monthly milk allotment. A maximum of one (1) pound of cheese per month is allowed without medical documentation and a maximum of four (4) pounds with medical documentation of a qualifying condition. 4 If no cheese is issued, a maximum of 12 quarts of milk may be substituted with evaporated milk (16 cans). This leaves one gallon of fluid milk in the food package. 5 If one pound of cheese is issued, a maximum of 9 quarts of milk may be issued with evaporated milk (12 cans). This leaves one gallon of fluid milk in the food package. 6 If no cheese is issued, a maximum of 12 quarts of milk may be substituted with dry powder milk. This leaves one gallon of fluid milk in the food package. 7 If one pound of cheese is issued a maximum of 9 quarts of milk may be substituted with dry powder milk. This leaves one gallon of fluid milk in the food package. 8 Subtract from monthly milk allotment. Medical documentation required for a child to receive any tofu.

See Attachment FP-35 for more information on milk substitutions

FP-258

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-27

WOMEN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD
Milk2 Cheese Tofu8 Eggs Juice
Cereal Beans/Peas and/or Peanut Butter Fruit and Vegetable Whole Grain or Alternative Fish1

PREGNANT (Singleton), MOSTLY
BREASTFEEDING
Food Package V 22 quart equivalents 3 6 pounds 4,5 12 pounds 1 dozen 3 (46-48 oz) containers or 3-12 oz cans frozen or 3-11.5 oz cans pourable 36 ounces 1 pound bag dried or 4 (14-16 oz) cans and
1 container (16-18 oz)
$8.00
16 oz
N/A

EXCLUSIVELY BREASTFEEDING11, PREGNANT WITH
MULTIPLE FETUSES, MOSTLY BREASTFEEDING
MULTIPLES7 Food Package VII 24 quart equivalents3 6 pounds4,5,6 12 pounds 2 dozen 3 (46-48 oz) containers or 3-12 oz cans frozen or 3-11.5 oz cans pourable 36 ounces 1 pound bag dried or 4 (14-16 oz) cans and
1 container (16-18 oz)
$10.00
16 oz
30 oz

NONBREASTFEEDING,
SOME BREASTFEEDING
Food Package VI 16 quart equivalents3 4 pounds4,5 12 pounds 1 dozen 2 (46-48 oz) containers or 2-12 oz cans frozen or 2-11.5 oz cans pourable 36 ounces 1 pound bag dried or 4 (14-16 oz) cans OR
1 container (16-18 oz)
$8.00
N/A
N/A

1 Additional item authorized for Food Package VII only.

2 May substitute up to maximum quart equivalents of lactose reduced milk for milk.

3 Substitution amounts for fluids milk include:

ITEM

FLUID MILK EQUIVALENTS

Cheese, 1 pound

3 quarts4,5

Evaporated milk, non-fat (12 oz)

4 cans equal 3 quarts9

Nonfat or low-fat dry milk

1-3 quart box equal to 3 quarts10

Tofu, 1 pound

1 quart8

4 Subtract from monthly milk allotment. A maximum of one (1) pound of cheese per month is allowed without medical documentation of a qualifying condition. Women in Food Package VII are allowed up to a total of three (3) pounds of cheese per month without medical documentation. 5 Substitute up to six (6) pounds of cheese with medical documentation for Food Package V and VII and up to four (4) pounds of cheese for Food Package VI with medical documentation.

FP-259

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-27 (cont'd)

6 The standard package includes one (1) pound of cheese; staff may substitute up to an additional five (5) pounds of cheese with medical documentation for a total of six (6) pounds. 7 Women exclusively breastfeeding multiples can receive 1.5 times the amounts listed. 8 One (1) pound of tofu can be substituted for 1 quart of milk. Subtract from monthly milk allotment. Medical documentation must be on file to receive more than four (4) pounds of tofu for Food Packages V and VI and to receive more than six (6) pounds for Food Package VII. 9 For postpartum women not receiving cheese, a maximum of 12 quarts of milk may be substituted with evaporated milk or 9 quarts when one (1) pound of cheese is issued. In both cases this leaves one gallon of fluid milk. For pregnant and breastfeeding women not receiving cheese, a maximum of 18 quarts of milk may substituted with evaporated milk or 15 quarts when one (1) pound of cheese is issued. In both cases, one gallon of fluid milk is left. For exclusively breastfeeding women 21 quarts of milk may be substituted with evaporated milk. They would receive two (2) pounds of cheese with this package. 10 For postpartum women not receiving cheese a maximum of 12 quarts of milk may be substituted with dry powder milk or 9 quarts with one (1) pounds of cheese. In both cases one gallon of fluid milk is left. For pregnant and breastfeeding women not receiving cheese, a maximum of 18 quarts of milk may substituted with dry powder milk or 15 quarts when one (1) pound of cheese is issued. In both cases one gallon of fluid milk is left. For exclusively breastfeeding women 21 quarts of milk of milk may be substituted with dry powder milk. They would receive two (2) pounds of cheese with this package. 11Women exclusively breastfeeding multiple infants receive 1.5 times the amounts of food listed in the table for women exclusively breastfeeding women. Items not in full packages can be averaged over two months (e.g., 1.5 jars of peanut butter with one jar being issued one month and two jars to next month).

FP-260

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-28

ALTERNATIVE FOOD PACKAGE FOR FFF INFANTS (0-3 MONTHS)
Maximum Monthly Amounts Contract Standard Formulas

TYPE

SIZE

MAXIMUM AMOUNT

Ready-To-Feed

104-8 oz containers

832 fluid ounces

This food package consists of five vouchers per month.

ALTERNATIVE FOOD PACKAGE FOR FFF INFANTS (4-5 MONTHS)
Maximum Monthly Amounts Contract Standard Formulas

TYPE

SIZE

MAXIMUM AMOUNT

Ready-To-Feed

112-8 oz containers

896 fluid ounces

This food package consists of five vouchers per month.

ALTERNATIVE FOOD PACKAGE FOR FFF INFANTS (6-11 MONTHS)
Maximum Monthly Amounts Contract Standard Formulas

TYPE Ready-To-Feed Cereal, Infant

SIZE 80-8 oz containers 3-8 oz boxes, dry

MAXIMUM AMOUNT 640 fluid ounces 24 ounces

Infant fruit and vegetables

32-4 oz jars

128 ounces

This food package consists of six (6) vouchers per month.

FP-261

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-28 (cont'd)

ALTERNATIVE FOOD PACKAGES FOR CHILDREN AND WOMEN WITH QUALIFYING MEDICAL CONDITIONS:
MAXIMUM MONTHLY AMOUNTS AUTHORIZED FOR FORMULAS

FOOD Ready-To-Feed Formula

SIZE 113-8 oz containers

MAXIMUM AM0UNTS 910 fluid ounces

ALTERNATIVE FOOD PACKAGES FOR CHILDREN AGES 1 TRHOUGH 5 YEARS MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD
UHT Milk
Cereal

SIZE
64-8 ounce OR half pint boxes
3-12 oz boxes

MAXIMUM AMOUNTS
512 fluid ounces
36 ounces

Juice

21 (5.5 to 6 oz) cans 128 fluid ounces

Peanut Butter

1 container (16-18 oz) 18 ounces

Whole Grain Bread or alternative

2-16 oz loaves

This food package consists of six (6) vouchers.

32 oz

FP-262

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-28 (cont'd)

ALTERNATIVE FOOD PACKAGES FOR PREGNANT AND MOSTLY BREASTFEEDING WOMEN
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

PREGNANT AND
MOSTLY BREASTFEEDING
Food Package V

EXCLUSIVELY BREASTFEEDING,
MOSTLY BREASTFEEDING MULTIPLES, AND PREGNANT WITH MULTIPLE FETUSES
Food Package VII

UHT Milk, lowfat
Cheese
Whole grains or Alternative

88 - 8 ounce OR half pint boxes
16 oz

96 - 8 ounce OR half pint boxes
1 lb cheese 16 oz

Cereal

3 - 12 oz boxes

3 - 12 oz boxes

Juice

24 (5.5 to 6 oz) cans

24 (5.5 to 6 oz) cans

Peanut Butter

2 containers (16-18 oz 2 containers (16-18 oz

each)

each)

Beans/Peas

N/A

8 (14 to 16 oz) can

SOME BREASTFEEDING
AND NON-BREASTFEEDING
Food Package VI
64 8 ounce OR half pint boxes
N/A
3 - 12 oz boxes 16 (5.5 to 6 oz) cans
1 container (16-18 oz)
N/A

Fish

N/A

6 5 oz cans

Fruit and

$8

$10

vegetable

Note* These food packages consist of 6-8 vouchers

N/A $8

FP-263

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-29

How to Convert Breastfeeding Packages

Step1: List food allowed in smaller package Step 2: Subtract amounts of foods on vouchers already cashed Step 3: Issue remaining foods using a 999 voucher

Sample: Mostly to Some for Standard Food Packages

Can not be done mid-month if: 1) Voucher code W02 cashed or 2) Voucher codes 041 and 040 both have been cashed or 3) Three (3) or more regular vouchers have been cashed

W01 to W21

(Mom returns voucher codes W02 and 040)

Milk Dry milk Juice Cheese Eggs Cereal Beans/PB

Allowed 2 gal 1 box

2

1

1

36

1 or 1

041

1 gal

2

1

36

Remaining 1 gal 1 box

0

1

0

0

1 or 1

W01

1 gal 1

1

1 PB

Issue

gal 0

0

0

0

0

0

Issue VC A34. Client may keep P01 voucher. Mom would return W02 and 040.

F/veg $8
$8
$8

Allowed 040 Remaining W01 Issue

W01 to W21

(Mom returns voucher codes W02 and 041)

Milk Dry milk Juice Cheese Eggs Cereal

2 gal 1 box

2

1

1

36

1 gal

1

1 gal 1 box

1

1

1

36

1 gal 1

1

1

gal 0

1

0

1

36

Beans/PB F/veg

1 or 1

$8

1 or 1

$8

1 PB

0

$8

It's okay if P01 has been cashed.

Issue VC A34 and W71. Client may keep P01voucher.

If only VC 041 has been used she keeps W01 and P01. You issue VC A34.

If only VC 040 has been used She keeps W01 and P01. You issue VC A34 and W71.

If only VC W01 has been used She keeps 041 and P01. You issue VC A34.

FP-264

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-29 (cont'd)

Sample: Exclusively to Mostly Breastfeeding

Can not be done mid-month if: 1) Voucher code P02 has been cashed or 2) Voucher code W03 has been cashed or 3) Voucher codes W82 and 039 has been cashed

W41 to W01

(mom returns voucher codes P02, 039, W03)

Milk Dry Juice Cheese Eggs Cereal Beans/PB

milk

Allowed 4 1

3 1

1

36 oz 1 and 1

W82

2

2

1

36

Remaining 2 1

1 1

0

0

1 and 1

W02

1

1 beans

Remaining 1 1

1 1

0

0

1 PB

Issue VC 040 and A35. Replace P02 with P01. Mom returns P01, 039, W03.

Whole Grain 16 oz
16 16 0

F/veg $8 $8 $8

W41 to W01 (mom returns voucher codes P02, W82, W03)

Milk Dry Juice Cheese Eggs Cereal Beans/PB Whole

milk

Grain

Allowed 4 1

3 1

1

36 oz 1 and 1 16 oz

039

1

1

1

Remaining 3 1

2 1

0

36

1 and 1 16

W02

1

1 beans 16

Remaining 2 1

2 1

0

0

1 PB

0

Issue VC 040, 040 and A35. Replace P02 with P01. Mom returns P01, 039, W03.

F/veg $8 $8 $8

If only VC W82 has been used - she keeps W02. You issue VC 040 and A35. Replace P02 with P01.

If only VC 039 has been used She keeps W02. You issue VC 040, 040 and A35. Replace P02 with P01.

If only VC W02 has been used she keeps W82. You issue VC 040 and A35. Replace P02 with P01.

FP-265

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-29 (cont'd)

Special Voucher Codes Used in Converting Standard Food Packages

A34 Milk: 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
A35 Dry Milk: 1-3 quart box non-fat dry powder

Cheese: 1-16 oz package

Peanut Butter: 1 container (16-18 oz) 040 Milk: 1 gallon low fat (fat-free, 1%, 2%) No whole milk Least
expensive brand

Juice: W71 Juice:

1-46 oz container or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Eggs: 1 dozen

Cereal: No more than 36 oz

FP-266

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-30

Infant Formulas with Sequencing Exceptions

Alimentum, Pregestimil LIPIL

Age at Issuance

Package Package Assigned Issued

Amount Issued

0 2 month 15 days

R**

R**

7 powder

2 month 16 days 5 months 15 days

S**

8 powder

5 months 16 days 11 months 15 days

T**

6 powder +

*5 months 16 days 11 months 15 days

S**

S**

8 powder

* Alternative package for infants unable to eat solids foods ** Insert package number for type of formula being issued + Receives infant cereal and infant fruits and vegetables in addition to formula

Nutramigen AA LIPIL

Age at Issuance

Package Package Assigned Issued

Amount Issued

0 2 month 15 days

R**

R**

8 powder

2 month 16 days 5 months 15 days

S**

9 powder

5 months 16 days 11 months 15 days

T**

7 powder +

*5 months 16 days 11 months 15 days

S**

S**

9 powder

* Alternative package for infants unable to eat solids foods ** Insert package number for type of formula being issued + Receives infant cereal and infant fruits and vegetables in addition to formula

Similac PM 60/40
Age at Issuance
0 3 month 15 days 3 month 16 days 5 months 15 days 5 months 16 days 6 months 15 days

Package Assigned
R14

Package Issued
R14 S14 V14

Amount Issued
8 powder 9 powder 7 powder+

6 months 16 days 11 months 15 days

T14

6 powder+

*6 months 16 days 11 months 15 days

S

S14

9 powder

* Alternative package for infants unable to eat solids foods

+Receives infant cereal and infant fruits and vegetables in addition to formula

FP-267

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-31

WIC Approved Formulas/Medical Foods

Contract Infant Formula: a, b
Similac Advance with Iron Similac Advance EarlyShield Isomil Advance with Iron

Ross-Abbott Laboratories Ross-Abbott Laboratories Ross-Abbott Laboratories

Contract Infant Formula Prescription Required: a, b

Similac Sensitive

Ross-Abbott Laboratories

Similac Sensitive RS
Similac Go & Grow EarlyShield Milk-Based

Ross-Abbott Laboratories Ross-Abbott Laboratories

Similac Go & Grow Soy-Based

Ross-Abbott Laboratories

Non-Contract Formulas/Medical Foods Requiring a Prescription and Diagnosis: a,b,c

Formula

Manufacturer

Formula

Manufacturer

Formula

Manufacturer

A-Soy
Acerflex Add-Ins Advera Alimentum AlitraQ Boost Boost Glucose Control Boost High Protein Boost Kid Essentials Boost Kid Essentials 1.5 Boost Kid Essentials 1.5 w / fiber Boost Plus Boost Pudding Bright Beginnings Pediatric Nutritional Drink

PBM Products Nutricia Nutricia Ross Products Ross Products Ross Products Nestl
Nestl
Nestl
Nestl
Nestl
Nestl
Nestl Nestl
Bright Beginnings
(PBM Products)

Bright Beginnings Pediatric Nutritional Drink w/Fiber Bright Beginnings Soy Pediatric Nutritional Drink Calcilo XD Carnation Instant Breakfast Essentials Carnation Instant Breakfast Essentials, No Sugar Added Carnation Instant Breakfast Lactose Free Carnation Instant Breakfast Lactose Free Plus

Bright Beginnings
(PBM Products)
Bright Beginnings
(PBM Products)
Ross Products Nestl
Nestl
Nestl
Nestl

Carnation Instant Breakfast Lactose Free VHC Compleat Compleat Pediatric Complex MSUD Amino Acid Bars Crucial Cyclinex 1 Cyclinex 2 Duocal EO28 Splash EleCare EleCare with DHA & ARA EnfaCare LIPIL
Enfamil AR
Enfamil Human Milk Fortifier

Nestl
Nestl
Nestl
Applied Nutrition Corporation
Nestl Ross Products Ross Products Nutricia Nutricia Ross Products
Ross Products
Mead Johnson Mead Johnson
Mead Johnson

Enfamil Human Milk Fortifier with iron

Mead Johnson

FP-268

GA WIC 2010 PROCEDURES MANUAL

Formula Enfamil Enfagrow Soy Enfamil Premature LIPIL 20
Enfamil Premature LIPIL 20 with iron
Enfamil Premature LIPIL 24 Enfamil Premature LIPIL 24 with iron Enfamil Soy LIPIL Enfaport LIPIL Enlive Ensure Ensure with Fiber Ensure High Protein Ensure Plus Ensure Plus HN Ensure Pudding Fiber Source HN Forta Drink Forta Shake Glucerna
Gluco-Pro
Glutarex-1 Glutarex-2 Hominex-1 Hominex-2 Introlite Isomil DF
IsoPro
IsoSource 1.5

Manufacturer
Mead Johnson
Mead Johnson
Mead Johnson
Mead Johnson
Mead Johnson
Mead Johnson Mead Johnson Ross Products Ross Products
Ross Products
Ross Products
Ross Products
Ross Products
Ross Products
Nestl
Ross Products Ross Products Ross Products Nutrition Medical Ross Products Ross Products Ross Products Ross Products Ross Products Ross Products Nutrition Medical Nestl

Formula

Manufacturer

IsoSource HN

Nestl

I-Valex-1

Ross Products

I-Valex-2

Ross Products

Jevity

Ross Products

KetoCal 3:1 Nutricia

KetoCal 4:1 Nutricia

Ketonex-1 Ross Products

Ketonex-2 Ross Products

L-Elemental

Nutrition Medical

L-Elemental Nutrition

Hepatic

Medical

L-Elemental Nutrition

Plus

Medical

L-Elemental Nutrition

Pediatric

Medical

Lipistart

Vitaflow

Lo*Pro

Med-Diet Labs

MCT Oil

Nestl

Methionaid Nutricia

Microlipid Nestl

Monogen

Nutricia

MSUD Analog

Nutricia

MSUD Maxamaid

Nutricia

MSUD Maxamum

Nutricia

MSUD-1

Nutricia

MSUD-2

Nutricia

Neocate Infant

Nutricia

Neocate

Infant DHA Nutricia

& ARA

Neocate Junior

Nutricia

Neocate One+ Nutricia

NeoSure

Ross Products

Nepro

Ross Products

Nestl Good

Start

Nestl

Premature 24

Attachment FP-31 (cont'd)

Formula Nestl Good Start Soy PLUS
(formerly Nestl Good Start Supreme Soy DHA & ARA)
Nestl Good Start Soy PLUS 2
(formerly Nestl Good Start 2 Supreme Soy DHA & ARA)
Nitro-Pro
NovaSource Renal Nutramigen AA LIPIL Nutramigen LIPIL Nutramigen LIPIL with Enflora LGG Nutren 1.0 Nutren 1.0 with Fiber Nutren 1.5 Nutren 2.0 Nutren Glytrol Nutren Junior Nutren Junior Fiber Nutren Pulmonary Nutren Replete with Fiber NutriHep NutriVent Osmolite Osmolite HN Plus Parents Choice Soy PediaSure

Manufacturer
Nestl
Nestl
Nutrition Medical Nestl Mead Johnson Mead Johnson Mead Johnson Nestl Nestl Nestl Nestl Nestl Nestl Nestl Nestl
Nestl Nestl Nestl Ross Products Ross Products Wyeth Nutrition Ross Products

FP-269

GA WIC 2010 PROCEDURES MANUAL

Formula PediaSure w/Fiber PediaSure Enteral PediaSure Enteral w/Fiber Pepdite Junior Peptamen Peptamen 1.5 Peptamen AF Peptamen Junior Peptamen Junior Fiber Peptamen Junior 1.5 Peptamen Junior with Prebio Peptamen OS (formerly
Peptinex 1.0)
Peptamen OS 1.5
(formerly Peptinex 1.5)
Perative Periflex Advance
Periflex Infant
Periflex Junior Phenex-1 Phenex-2
PhenylAde 40Drink Mix
PhenylAde 60Drink Mix
PhenylAde Amino Acid Bars

Manufacturer Ross Products
Ross Products
Ross Products
Nutricia Nestl Nestl Nestl
Nestl
Nestl
Nestl
Nestl
Nestl
Nestl
Ross Products Nutricia Nutricia North America Nutricia Ross Products Ross Products Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation

Formula PhenylAde Amino Acid Blend
PhenylAde Drink Mixes
PhenylAde Essential Drink PhenylAde MTE Amino Acid Blend Phenyl-Free 2 Phenyl-Free 2HP Phlexy 10 Bar Phlexy 10 Capsules Phlexy 10 Drink Mix
PKU-Express
PKU-Gel
Polycal Polycose
Portagen
Pregestimil LIPIL Pregestimil LIPIL 24 ProBalance Product 3200AB Product 3232 A Product 80056 ProMod Promote
Pro-Peptide
Pro-Peptide for Kids Pro-Peptide VHN Pro-Phree

Manufacturer Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Mead Johnson Mead Johnson
Nutricia
Nutricia
Nutricia
Vitaflo Limited Vitaflo Limited Nutricia Ross Products Mead Johnson Mead Johnson Mead Johnson Nestl Mead Johnson Mead Johnson Mead Johnson Ross Products Ross Products Nutrition Medical Nutrition Medical Nutrition Medical Ross Products

FP-270

Attachment FP-31 (cont'd)

Formula Propimex-1 Propimex-2
Protifar
ProViMin Pulmocare
RE/GEN
Renalcal Resource 2.0 Resource Benecalorie Resource Benefiber Resource Beneprotein Resource Breeze Ross CHO Free (RCF) Scandical Calorie Booster Scandishake Scandishake Lactose Free Scandishake Sugar Free Similac Human Milk Fortifier with iron Similac Natural Care

Manufacturer Ross Products Ross Products Nutricia North America Ross Products Ross Products Nutra/ Balance Nestl Nestl Nestl
Nestl
Nestl
Nestl
Ross Products
Scandipharm
Scandipharm Scandipharm
Scandipharm
Ross Products
Ross Products

Similac PM 60/40 Similac Special Care Advance 20

Ross Products Ross Products

Similac Special Care Advance with Iron 20

Ross Products

Similac Special Care Advance 24

Ross Products

GA WIC 2010 PROCEDURES MANUAL

Formula Similac Special Care Advance with Iron 24

Manufacturer Ross Products

Similac Special Care Advance with Iron 30

Ross Products

Suplena Tolerex TwoCal HN Tyrex-1 Tyrex-2 UCD-2
Ultra-Pro
Vital High Nitrogen Vital Jr. Vivonex Pediatric Vivonex Plus

Ross Products Nestl Ross Products Ross Products Ross Products Nutricia Nutrition Medical
Ross Products
Ross Products
Nestl
Nestl

Formula Vivonex T.E.N. XLeu Analog XLeu Maxamaid XLeu Maxamum XLYS, XTrp Analog XLys, XTrp Maxamaid XLys, XTrp Maxamum XMet Analog XMet Maxamaid XMet Maxamum XMTVI Analog XMTVI Maxamaid

Manufacturer Nestl Nutricia Nutricia Nutricia Nutricia Nutricia Nutricia Nutricia Nutricia Nutricia Nutricia Nutricia

Attachment FP-31 (cont'd)

Formula XMTVI Maxamum XPhe , XTyr Maxamaid XPhe Maxamaid XPhe Maxamum XPhe Maxamum Drink XPHE, XTyr Analog XPTM Analog

Manufacturer Nutricia Nutricia Nutricia Nutricia
Nutricia
Nutricia Nutricia

a. Ready-to-feed formula may be indicated in limited documented cases, such as (1) The participant's household has an unsanitary or restricted water supply or poor refrigeration; (2) The person caring for the participant may have difficulty in correctly diluting concentrated or powder forms; or (3) The formula is only available in a ready-to-feed form (4) In addition, participants with qualifying medical conditions who are assigned to Food Package III can also be issued ready-to-feed formulas for the additional reasons below: x If the ready-to-feed form better accommodates the participant's medical condition (Food Package III clients only); or x If the ready-to-feed form improves the participant's compliance in consuming the prescribed formula (Food Package III clients only).
b. If a physician orders a product that is not on this list, contact the Office of Nutrition to determine whether the product is authorized for distribution through the Georgia WIC Program.
c. Special formulas may be acquired through the Office of Nutrition. See the Georgia WIC Program Procedures Manual, Food Package Section for appropriate procedure and forms.

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Attachment FP-32

Formula Manufacturers

Carnation Nutritional Products
800 No. Brand Boulevard Glendale, California 91203 (800) 628-BABY [2229]

Nutra/Balance Products
7155 Wadsworth Way Indianapolis, Indiana 46219 (800) 432-3134

Mead Johnson Nutritional Group 2400 W. Lloyd Expressway Evansville, Indiana 47721-0001 (800) 247-7893 - Adult Products (800) BABY-123 [222-9123] - Pediatric Products
Med-Diet Laboratories, Inc. 3050 Ranchview Lane Plymouth, Minnesota 55447 (612) 550-2020; FAX (612) 550-2022 (800) 633-3438: Consumer Telephone Number
Nestl HealthCare Nutrition, Inc. (formerly Nestle Clinical Nutrition and Novartis Nutrition) 10801 Red Circle Drive Minnetonka, Minnesota 55343 (952) 848-6000 (800) 422-ASK2 [2752]: Infolink

Nutrition Medical 308 12th Avenue, South Buffalo, Minnesota 55313 (800) 569-7828
Ross Products Division, Abbott Nutrition 625 Cleveland Avenue Columbus, Ohio 43216 (800) 551-5838 (800) 227-5767: Consumer Information
Scandipharm, Inc. 2200 Inverness Center Parkway Suite 310 Birmingham, Alabama 35242 (800) 950-8085
Nutricia North America
9900 Belward Campus Drive, Ste. 100 Rockville, MD 20850
(800) 365-7354 FAX (301) 795-2301

Vitaflo Limited
Distributed Through:
Transitional Service and Operation 123 East Neck Road Huntington, New York 11743 (631) 547-5984

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Attachment FP-33

SPECIAL FORMULA ORDER FORM

I. TO BE COMPLETED BY DISTRICT/LOCAL STAFF

Date Faxed:

Rush Delivery: YES NO Office of Nutrition called and notified of incoming fax. Written medical documentation with medical diagnosis attached. Returned packing slip to the Office of Nutrition when formula was received.

1. Name of WIC client & WIC ID Number 2. Birth date
x "First Day To Use" date on vouchers for current issuance month x Infant age (in months & days) as of "First Day To Use" date 3. Diagnosis 4. Name of formula requested x Formula flavor (if applicable) 5. Product number/manufacturer of formula 6. Amount of formula needed for current month (number of cans / containers) x Amount of formula prescribed per month (total # of cans / containers) x Amount of formula on hand (number of cans / containers) 7. Type of formula: ready to feed, concentrate, powder, single use bottle, etc. (Provide justification for RTF formula) 8. Estimated time on formula 9. Formula issue month 10. Clinic name, contact person, and phone no. 11. Address/telephone number to ship formula

12. Prescribing Physician 13. District contact person 14. WIC/Nutrition Coordinator's signature or designee
II. TO BE COMPLETED BY OFFICE OF NUTRITION
1. Formula Cost of this order (including price per case) 2. Date order placed to formula company 3. Clinic/District's account number 4. Contact person at formula company/phone no. 5. Anticipated date of delivery 6. State Nutrition Program Consultant's signature & date
III. TO BE COMPLETED BY STATE WIC BUDGET OFFICER
1. Purchasing authorization number/initial date 2. Field Purchase Order # / initial date 3. WIC Financial Director's signature
_________________________________________________________________________________
OFFICE OF NUTRITION PHONE: (404) 657-2884 FAX: (404) 657-2886

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Attachment FP-34

Special Formula Order Tracking Form Sample

Clients Name: __________________

Date of Last Rx

Next Rx Due Date

P/U Code

Next Pick Up Date

Date Order Faxed to State

Amt of Formula Ordered

Amt of Formula Received

Date Order Received

Date Packing
Slip Faxed to
State

Date Client Picked Up

Amt. of Formula Issued

Amt. of Formula Leftover

9/1/2008 3/1/2009

12 cans (3

2A4

10/13/2008 9/29/2008 9 cans

cases) 10/3/2008 10/3/2008 10/14/2008 9 cans

10/31/200

8 cans (2

11/10/2008

8

6 cans

cases) 11/6/2008 11/6/2008 11/11/2008 9 cans

11/24/200

8 cans (2

12/8/2008

8

7 cans

cases) 12/3/2008 12/4/2008 12/10/2008 9 cans

12/29/200

8 cans (2

1/12/2009

8

8 cans

cases) 1/6/2009 1/7/2009 1/9/2009

9 cans

12 cans (3

2/9/2009 1/30/2009 9 cans

cases) 2/5/2009 2/5/2009 2/9/2009

9 cans

3 cans 2 cans 1 can
0 3 cans

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GA WIC 2010 PROCEDURES MANUAL
Special Formula Order Tracking Form

Attachment FP-34 (cont'd)

Clients Name: __________________

Date of Last Rx

Next Rx Due Date

P/U Code

Next Pick Up Date

Date Order Faxed to State

Amt of Formula Ordered

Amt of Formula Received

Date Order Received

Date Packing
Slip Faxed to
State

Date Client Picked Up

Amt. of Formula Issued

Amt. of Formula Leftover

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-35

Table: Cheese and Tofu Substitution
Note: When milk substitutions are provided, the full maximum monthly fluid milk allowance must be provided.

Children/Non-Breastfeeding and Some Breastfeeding Women:

Standard Milk Allotment 16 quarts

Cheese Substitution

For this amount of Give this amount of

cheese (lb)

fluid milk (gallon)

Plus this amount of powder milk OR evaporated milk "CHOOSE ONE"
Powder Milk (3qt) Evaporated Milk (12 oz)

0

4

0

0

1

3

1

4

2

2

0

0

3

1

1

4

4*

1

0

0

Tofu Substitution

For this amount of tofu (lb)

Give this amount of fluid milk (gallon)

0

4

2

3

4

3

6

2

8**

2

*Maximum amount of cheese which is allowed to be substituted for milk ** Maximum amount of tofu which is allowed to be substituted for milk

Pregnant and Mostly Breastfeeding Women:

Standard Milk Allotment 22 quarts

Cheese Substitution

For this amount of cheese (lb)

Give this amount of fluid milk (gallon)

Plus this amount of powder milk OR evaporated milk "CHOOSE ONE"
Powder Milk (3qt) Evaporated Milk (12 oz)

0

5

0

0

1

4

1

4

2

4

0

0

3

2

1

4

4

2

0

0

5

1

1

4

6*

1

0

0

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Attachment FP-35 (cont'd)

Tofu Substitution

For this amount of tofu (lb)

Give this amount of fluid milk (gallon)

0

5

2

5

4

4

6

4

8

3

10

3

12**

2

*Maximum amount of cheese which is allowed to be substituted for milk ** Maximum amount of tofu which is allowed to be substituted for milk

Exclusively Breastfeeding Women:

Standard Allotment 24 quarts of milk and one (1) pound of cheese

Cheese Substitution

For this amount of cheese (lb)

Give this amount of fluid milk (gallon)

Plus this amount of powder milk OR evaporated milk "CHOOSE ONE"
Powder Milk (3qt) Evaporated Milk (12 oz)

0

6

0

0

1

4

1

4

2

4

0

0

3

2

1

4

4

2

0

0

5

1

1

4

6*

1

0

0

Tofu Substitution

For this amount of tofu (lb)

Give this amount of fluid milk (gallon)

0

6

2

5

4

5

6

4

8

4

10

3

12**

3

*Maximum amount of cheese which is allowed to be substituted for milk ** Maximum amount of tofu which is allowed to be substituted for milk ***The amount is in addition to the standard one (1) pound of cheese issued to all exclusively breastfeeding women.

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Attachment FP-36

Form #1 Instructions Medical Documentation Form for WIC Special Formulas and Approved WIC Foods
A. Form Explanation
1. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods is designated as "Form #1," as identified by the "1" in the box in the upper right corner on both the first and second page of the form.
2. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) is used to prescribe any formula/medical food requiring a prescription for issuance by the Georgia WIC Program. These formulas/medical foods are outlined below:
a) Any contract infant formula requiring a prescription for an infant (e.g., Similac Sensitive R.S.)
b) Any Georgia WIC approved non-contract soy infant formula for an infant (e.g., ProSobee LIPIL or Enfamil Soy LIPIL)
c) Any exempt infant formula for an infant (e.g., Similac NeoSure) d) Any medical food prescribed for infants, children, or women (e.g.,
PediaSure, Hominex-1, Nutren Junior, Similac Special Care 24) e) Any infant formula or exempt infant formula prescribed for
children or women (e.g., Similac Advance EarlyShield, EleCare)
3. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) cannot be used solely to provide medical documentation for issuance of food substitutions such as soy milk, tofu, or extra cheese. Please refer to Form #2 (Referral Form and Medical Documentation for Special Food Substitutions) for food substitutions.
4. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) consists of five parts WIC participant information at the top of the form followed by four (4) sections for documentation of diagnoses, the prescribed formula/medical foods, the allowed WIC supplemental foods, and the provider's information. All four (4) sections plus the participant information must be completed on the form in order for the form to be accepted by the WIC clinic. If information is missing or incomplete, the CPA should attempt to contact the prescribing medical office/clinic to obtain a verbal order and follow the instructions in Section VIII (Medical Documentation) of the Food Package Section for documenting verbal orders and obtaining necessary verification.

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Attachment FP-36 (cont'd)

5. Formula products requiring a prescription, medical foods, and supplemental foods cannot be issued to WIC clients with qualifying medical conditions unless complete, up-to-date written medical documentation or a verbal order is present and documented. It is unacceptable and against program policy to issue formula, medical foods, or supplemental foods for one month until the client can provide the required documentation. Documentation must be present prior to issuance.
6. Health care providers are not required to use the Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) for the prescription of formulas and medical foods, but its use is strongly encouraged to reduce the likelihood of missing information when other forms are used. However, medical documentation can also be provided on a physician's prescription pad, private medical office letterhead, or District/County letterhead, as long as all of the required information is present.
7. The completed medical documentation may be faxed to the clinic, sent electronically, delivered in person, or mailed.
8. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) is available on the Georgia WIC Program website at: http://health.state.ga.us/programs/wic/wicformula.asp .
B. Form Components
1. WIC Participant Information: The WIC participant's first and last name, date of birth, and (for infants/children) the parent/caregiver's name must be listed at the top of the form.
2. Section #1: Qualifying Medical Conditions
a) This section is where the medical diagnosis(es) is documented that justifies the need for the special formula or medical food.
b) Both the name of the medical condition and the applicable ICD-9/ICD-10 code must be listed.
c) Resources for ICD-9/ICD-10 codes can be found at: x http://www.who.int/classifications/icd/en/
x http://www.cdc.gov/nchs/about/major/dvs/icd9des.htm
x http://en.wikipedia.org/wiki/List_of_ICD-9_codes x http://en.wikipedia.org/wiki/ICD-10

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-36 (cont'd)

3. Section #2: Special Formula Requested
a) This section is where the brand name of the prescribed special formula or medical food is listed. The full name of the prescribed product should be listed (e.g., "Neocate Infant" rather than "Neocate") to avoid confusion. If the full product name is not specified, the CPA must call the prescribing health care provider for clarification and document the complete information on the form. The updated information must be signed and dated by the CPA.
b) The amount of the product must be listed in ounces per day. If the prescribed product is in concentrate or powdered form, the amount per day is listed in reconstituted (i.e., after preparation with water) fluid ounces per day based on standard dilution. Formula is issued based on standard reconstitution directions for making 20 calorie/oz. formula. If the health care provider is instructing a participant to prepare the formula with less water to make it more concentrated (e.g., 24 calories/oz.), then beware that the participant may be eligible for more formula if they are not already receiving the maximum allowed or their full nutritional value.
c) The prescribing health care provider must identify the form of the product by checking the "powder," "concentrate," or "ready-to-feed" box. If "ready-to-feed" is selected, the CPA must determine if the participant meets WIC ready-to-feed issuance requirements and must document those reasons in the participant's record. See page FP-15 for more details.
d) The prescribing health care provider must indicate the intended length of time the participant will need to use the special formula/medical food product based on the participant's condition. This is only an estimate. However, if the planned length of use is less than 6 months (e.g., 1 or 2 months), the participant must provide the WIC clinic with an updated medical documentation form to continue on the special formula/medical food beyond the 1 month or 2 months initially indicated. Clinics cannot issue vouchers beyond the period of time listed in the "planned length of use" in Section #2. For example, if an infant has medical documentation to receive EleCare for 2 months, the clinic may only issue 2 months worth of vouchers. New medical documentation must be presented to the clinic at the end of

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-36 (cont'd)

the 2-month time period in order for the infant to continue receiving EleCare.
4. Section #3: WIC Foods
a) This section is where the prescribing health care provider indicates which WIC supplemental foods the participant can or cannot receive based on the participant's medical condition.
b) The provider must complete either "A" or "B" of this section. c) If the participant is allowed to consume all supplemental
foods, the provider must initial the line in section "A." d) If the participant cannot eat certain foods due to the medical
condition, the provider must check all applicable boxes in section "B" to indicate which foods cannot be issued. e) The provider can list any special comments in the "Comments" box on the table. This area can be used to indicate special situations (e.g., the participant can only drink soy milk or goat milk). f) If the formula is to replace milk in the diet, then milk should be checked on the contraindicated supplemental food box.
5. Section #4: Health Care Provider Information
a) This section is where the prescription date is recorded and the prescribing health care provider's name, signature, credentials, and contact information are documented.
b) All five boxes must be completed. c) The form can only be signed by the types of providers listed. d) The medical office/clinic contact information can be stamped. e) The provider's signature cannot be a stamped signature.
6. Page 2: The back of the form contains information for completing the form, definitions, examples, and the non-discrimination statement.

C. Evaluation of Medical Documentation
1. The CPA must carefully evaluate the diagnosis, formula/medical food prescribed, supplemental foods allowed, and the WIC participant's existing anthropometric data and nutrition/health history.
2. The CPA must determine whether or not the prescription can be approved for WIC use based on WIC policies and procedures. Please refer to Section

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-36 (cont'd)

VIII (Medical Documentation) of the Food Package Section for additional guidance. CPAs must take into consideration:
a) Which formulas and medical foods are approved for issuance by the Georgia WIC Program,
b) The maximum allowed quantities of special formulas and medical foods based on participant category (infant, child, or woman), age, feeding method, and product form,
c) The intended use of the formula or medical food, d) The appropriateness of the diagnosis for the prescribed
formula or medical food, e) Non-specific diagnoses that are not acceptable for WIC
prescriptions and diagnoses requiring additional information (see page 2 of the form), f) The participant's age and existing health data.
3. The CPA must determine whether an appropriate state-created food package exists to meet the participant's needs or whether a 999 food package must be developed using state-created and/or District-created voucher codes.
4. The CPA must determine when the participant is required to bring updated medical documentation back to the clinic. a) If section #2 of the form indicates a time period of less than 6 months, new documentation is required at the end of that time period (e.g., 1 or 2 months after the date in section #4) or at the next certification, whichever comes first. b) If section #2 of the form indicates a time period of 6 or more months, new documentation is required in 6 months from the date listed in section #4 or at the next certification, whichever comes first.
5. Districts are encouraged to designate a contact person (e.g., Nutrition Manager, Nutrition Services Director) for CPAs to call when medical documentation questions arise.
6. Additional clarifying information can always be requested from the provider, if necessary, prior to the denial of a prescription.

D. Special Situations
1. Infants (ages 6-11 months) receiving exempt infant formulas or medical foods and who cannot tolerate any supplemental foods are eligible to receive formula at the higher maximum rate allowed for a 4-5 month old infant in place of the supplemental foods.

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-36 (cont'd)

a) The infant must be age 6-11 months old. b) The infant must be receiving an exempt infant formula or a
medical food. Infants receiving standard infant formulas requiring a prescription are not eligible to receive the higher maximum formula rate in place of the infant foods, even if the infant is unable to consume those foods. The ineligible formulas are Similac Sensitive, Similac Sensitive R.S., Similac Go & Grow EarlyShield Milk-Based, Similac Go & Grow SoyBased, Enfamil ProSobee LIPIL, Enfamil Soy LIPIL, Enfagrow Soy, Enfamil A.R. LIPIL, Nestl Good Start Soy PLUS, Nestl Good Start Soy PLUS 2, Parent's Choice Soy, and any other store brand soy-based standard infant formulas that are USDA approved. c) The provider must indicate under section #3 (WIC Foods) on the medical documentation form that the infant cannot consume both "infant cereal" and "baby food fruits and vegetables" by checking both boxes. If the infant cannot tolerate just one of the supplemental foods, the infant is not eligible to receive the additional formula quantity.
2. Ready-to-Feed Products a) Infants with medical documentation who are receiving exempt infant formulas or medical foods are eligible for two additional reasons to be issued the ready-to-feed form of a product: x If the ready-to-feed product better accommodates the participant's medical condition x If the ready-to-feed product improves the participant's compliance in consuming the prescribed product. b) Infants with medical documentation who are receiving the following formulas are not eligible for the additional two reasons listed above to issue the ready-to-feed version of a product: Similac Sensitive, Similac Sensitive R.S., Similac Go & Grow EarlyShield Milk-Based, Similac Go & Grow Soy-Based, Enfamil ProSobee LIPIL, Enfamil Soy LIPIL, Enfagrow Soy, Enfamil A.R. LIPIL, Nestl Good Start Soy PLUS, Nestl Good Start Soy PLUS 2, Parent's Choice Soy, and any other store brand soy-based standard infant formulas that are USDA approved. c) The reason for issuance of a ready-to-feed product must be clearly documented in the participant's WIC record.
3. Milk Issuance

FP-283

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-36 (cont'd)

a) Children and women with medical documentation who are receiving any formula or medical food and who have a qualifying medical condition (Food Package III) are eligible to receive whole milk. Milk must be allowed per the provider's medical documentation (i.e., the "milk" box must not be checked as contraindicated in section #3). If milk is allowed, children/women can be issued whole milk at the CPA's professional discretion if it is appropriate for the participant's medical condition (e.g., Failure To Thrive).
b) If milk is allowed, children ages 12-23 months old cannot be issued low-fat milk for any reason, even with medical documentation.
c) Tofu, soy milk, goat milk, lactose-reduced milk, or extra cheese can be substituted for milk for clients who are providing other medical documentation (Food Package III) by following the procedures for milk substitutions previously outlined by participant category in the Food Package Section.
4. Children and Women Needing Infant Cereal a) Children and women with medical documentation who are receiving any formula or medical food and who have a qualifying medical condition (Food Package III) can be issued infant cereal in place of adult cereal. b) Children and women who, for example, have developmental delays or swallowing disorders may be issued up to 32 ounces of infant cereal in place of 36 ounces of adult cereal. c) The CPA can make this determination or the provider can make the substitution request in the comments section on the medical documentation form in section #3 (WIC Foods).
E. Formula Quantity To Issue 1. As stated on page 2 of the medical documentation form, infant WIC participants are to be issued the full maximum quantity of formula allowed per month regardless of the quantity prescribed per day under section #2 of the form. This ensures that the infants receive the full nutritional benefit. The full maximum quantity allowed depends upon the infant's age, feeding method (Mostly Breastfed or Fully Formula Fed), the product form (powder, concentrate, or ready-to-feed), and the product package size. 2. Child and woman WIC participants are to be issued the quantity of formula or medical food prescribed, up to the maximum quantity allowed by WIC regulations, under section #2 of the form.
FP-284

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-36 (cont'd)

F. Valid Dates
1. New medical documentation (Form #1) of a prescribed special formula or medical food is required every six (6) months, at a minimum, and at every recertification/certification / mid-certification (if the medical documentation on file was signed and dated by the health care provider more than 30 days prior to the recertification/certification / midcertification). For example, if the caregiver of an infant client provides medical documentation on Form #1 when the infant is age 5 months 2 days old, a new, updated copy of the medical documentation must also be provided at the time of the mid-certification if it occurs when the infant is more than 6 months 2 days old. Likewise, if the caregiver of a child participant provides medical documentation for a prescribed formula/medical food using Form #1 at age 22 months 25 days, a new, updated copy of the medical documentation must also be provided at the next subcert, if that recertification occurs more than 30 days after the medical documentation was signed by the provider (e.g., when the child is age 24 months old).
2. Each time new medical documentation (Form #1) is submitted by a WIC participant, it must include all required information and must be signed and dated by the health care provider no more than 30 days ago. Clinics cannot accept medical documentation (Form #1) where the date under section #4 has simply had a line drawn through it and a new date added. A new form must be submitted.

FP-285

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-37

Page 1 of Medical Documentation Form (Form #1)

FP-286

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-37 (cont'd)

Page 2 of Medical Documentation Form (Form #1)

FP-287

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-38

Form #2 Instructions Referral Form and Medical Documentation for Special Food Substitutions
A. Form Explanation
1. The Referral Form and Medical Documentation for Special Food Substitutions is designated as "Form #2," as identified by the "2" in the box in the upper right corner on both the first and second page of the form.
2. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) is used for two primary purposes to provide medical referral data on a WIC participant/applicant and to provide the required medical documentation needed to authorize special food substitutions in place of all or part of the milk allowance for women and children. The form may be used to provide referral data only, to authorize a special food substitution only, or for both.
3. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) cannot be used to prescribe any formula/medical food requiring a prescription for issuance by the Georgia WIC Program. Please refer to Form #1 (Medical Documentation Form for WIC Special Formulas and Approved WIC Foods) for prescribing special formulas or medical foods.
4. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) consists of four parts WIC participant information and medical office contact information at the top of the form followed by three (3) sections for documentation of medical referral data, the prescription of milk substitutions for children, and the prescription of milk substitutions for women. Only the WIC participant information and the medical office contact information is required to be completed on every form. The applicable section(s) should be completed for each participant depending upon whether the form is being used for medical referral data only, for the prescription of special food substitutions only, or for both. If a special food substitution is being prescribed and any information is missing or incomplete in the applicable section, the CPA should attempt to contact the prescribing medical office/clinic to obtain a verbal order and follow the instructions in Section VIII (Medical Documentation) of the Food Package Section for documenting verbal orders and obtaining necessary verification.
5. Special food substitutions requiring medical documentation cannot be issued to WIC clients unless complete, up-to-date written medical documentation or a verbal order is present and documented. It is

FP-288

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-38 (cont'd)

unacceptable and against program policy to issue special food substitutions for one month until the client can provide the required documentation. Documentation must be present prior to issuance.
6. Health care providers are not required to use the Referral Form and Medical Documentation for Special Food Substitutions (Form #2) for the provision of medical referral data or for the prescription of special food substitutions for women and children, but its use is strongly encouraged to reduce the likelihood of missing information when other forms are used. However, referral data and medical documentation for special food substitutions can also be provided on a physician's prescription pad, private medical office letterhead, or District/County letterhead, as long as all of the required information is present.
7. The completed referral form (Form #2) may be faxed to the clinic, sent electronically, delivered in person, or mailed.
8. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) is available on the Georgia WIC Program website at: http://health.state.ga.us/programs/wic/wicformula.asp
B. Form Components
1. WIC Participant Information & Medical Office Contact Information: The WIC participant's first and last name, date of birth, and (for infants/children) the parent/caregiver's name must be listed at the top of the form along with the medical office/clinic contact information. This information must be completed on all referral forms regardless of what other information is being provided on the form (e.g., referral data only or prescription of special food substitutions or both).
2. Referral Data
a) This section is where the medical referral data are reported. Only applicable spaces should be completed based upon the WIC participant category (e.g., infant, child, or woman).
b) It is not mandatory to complete this section if prescribing a special food substitution.
c) If only referral data are being provided, the health professional who collected the data should sign the "Referral Data Provided By:" line and enter the date the form was completed.

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GA WIC 2010 PROCEDURES MANUAL

Attachment FP-38 (cont'd)

3. Authorization of Special Food Substitutions for Children
a) This section is where special food substitutions are prescribed in place of all or part of the milk allowance for children ages 12 months and older. If a food substitution is prescribed, all parts of this section must be completed in full.
b) The diagnosed medical condition justifying the special food substitution is required. The diagnosis (e.g., lactose intolerance, vegan/vegetarian, milk protein allergy, etc.) should be consistent with the food substitution prescribed as outlined in Section VIII (Medical Documentation) of the Food Package Section.
c) The prescribing health care provider must check the box identifying which food substitution is being authorized. Federal regulations mandate that child WIC participants are required to have medical documentation authorizing the issuance of any quantity of soy milk, any quantity of tofu, or more than one (1) pound of cheese per month.
d) The exact quantity of the food substitution issued is determined by the CPA in conjunction with the participant or parent/caregiver. In some instances, only part of the milk allowance will be replaced with the special food substitution, depending upon the participant's medical needs and the substitution rates. When providing food substitutions for milk, the full nutritional benefit must be provided, which may require the issuance of some powdered, evaporated milk, or fluid milk. See Attachment FP-35 for more information on how to calculate milk substitutions and the maximum amounts of milk allowed to be substituted.
e) The prescribing health care provider must indicate the intended length of time the participant will need to use the special food substitution based on the participant's condition. This is only an estimate. However, if the planned length of use is less than 6 months (e.g., 4 months), the participant must provide the WIC clinic with an updated referral form (Form #2) containing medical documentation to continue on the special food substitution beyond the number of months initially indicated. Clinics cannot issue vouchers containing special food substitutions beyond the period of time listed in the "Planned Length of Use." For example, if a child has medical documentation to receive extra cheese for 2 months, the clinic may only issue 2 months worth of vouchers. New
FP-290

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-38 (cont'd)

medical documentation must be presented to the clinic at the end of the 2-month time period in order for the child to continue receiving extra cheese.
4. Authorization of Special Food Substitutions for Women
a) This section is where special food substitutions are prescribed in place of all or part of the milk allowance for women participants. If a food substitution is prescribed, all parts of this section must be completed.
b) The diagnosed medical condition justifying the special food substitution is required. The diagnosis (e.g., lactose intolerance, vegan/vegetarian, milk protein allergy, etc.) should be consistent with the food substitution prescribed as outlined in Section VIII (Medical Documentation) of the Food Package Section.
c) The prescribing health care provider must check the box identifying which food substitution is being authorized. Federal regulations mandate that women WIC participants are required to have medical documentation authorizing the issuance of extra tofu or extra cheese. Women are not required to have medical documentation in order to receive soy milk.
d) Extra tofu is defined for women participants as the issuance of: a. More than four (4) pounds of tofu per month for pregnant women and for postpartum women classified as Non-Breastfeeding, Some Breastfeeding, Mostly Breastfeeding. b. More than six (6) pounds of tofu per month for women classified as Exclusively Breastfeeding (one or more infants), Pregnant with Multiples (e.g., twins, triplets, etc.), Mostly Breastfeeding Multiples.
e) Extra cheese is defined for women participants as the issuance of: a. More than one (1) pound of cheese per month for women who are pregnant with only one fetus and for postpartum women classified as Non-Breastfeeding, Some Breastfeeding, or Mostly Breastfeeding. b. More than three (3) pounds of cheese per month for women who are classified as Exclusively Breastfeeding (one or more infants) or who are pregnant with multiple fetuses (e.g., twins, triplets, etc.) or Mostly Breastfeeding Multiples.

FP-291

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-38 (cont'd)

f) The exact quantity of the food substitution issued is determined by the CPA in conjunction with the participant. In some instances, only part of the milk allowance will be replaced with the special food substitution, depending upon the participant's medical needs and the substitution rates. When providing food substitutions for milk, the full nutritional benefit must be provided, which may require the issuance of some powdered, evaporated, or fluid milk. See Attachment FP-35 for more information on how to calculate milk substitutions and the maximum amounts of milk allowed to be substituted.
g) The prescribing health care provider must indicate the intended length of time the participant will need to use the special food substitution based on the participant's condition. This is only an estimate. However, if the planned length of use is less than 6 months (e.g., 4 months), the participant must provide the WIC clinic with an updated referral form containing medical documentation to continue on the special food substitution beyond the number of months initially indicated. Clinics cannot issue vouchers containing special food substitutions beyond the period of time listed in the "Planned Length of Use." For example, if a woman has medical documentation to receive extra cheese for 2 months, the clinic may only issue 2 months worth of vouchers. New medical documentation must be presented to the clinic at the end of the 2-month time period in order for the woman to continue receiving extra cheese.
5. Page 2: The back of the form contains information for completing the form, WIC policies, examples, and the non-discrimination statement.

C. Evaluation of Medical Documentation
1. The CPA must carefully evaluate the diagnosis, the food substitution authorized, and the WIC participant's existing anthropometric data and nutrition/health history.
2. The CPA must determine whether or not the prescription can be approved for WIC use based on WIC policies and procedures. Please refer to Section VIII (Medical Documentation) of the Food Package Section for additional guidance.
3. The CPA must determine whether an appropriate state-created food package exists to meet the participant's needs or whether a 999 food

FP-292

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-38 (cont'd)

package must be developed using state-created and/or District-created voucher codes. 4. The CPA must determine when the participant is required to bring updated medical documentation back to the clinic.
c) If the form indicates a "planned length of use" of less than 6 months, new documentation is required at the end of that time period (e.g., 1 or 2 months after the form date) or at the next certification, whichever comes first.
d) If the form indicates a "planned length of use" of 6 months, new documentation is required 6 months from the date listed on the form or at the next certification, whichever comes first.
5. Districts are encouraged to designate a contact person (e.g., Nutrition Manager, Nutrition Services Director) for CPAs to call when medical documentation questions arise.
6. Additional clarifying information can always be requested from the provider, if necessary, prior to the denial of a prescription.

D. Food Substitution Quantity to Issue 1. CPAs must use professional judgment to determine the amount of food substitution to be issued. 2. See Attachment FP-35 for the allowed maximum amounts of milk to be substituted. The amounts vary based on product being substituted, and WIC category and feeding type.
E. Valid Dates 1. New medical documentation for special food substitutions (Form #2) is required every six (6) months, at a minimum, and at every recertification/certification (if the medical documentation on file was signed and dated by the health care provider more than 30 days prior to the recertification/certification). For example, if the caregiver of a child participant provides medical documentation for the use of soy milk on Form #2 when the child is age 28 months 25 days old, a new, updated copy of Form #2 must also be provided at the time of the next recertification, even if the next recertification is due at age 30 months.
2. Each time new medical documentation for special food substitutions (Form #2) is submitted by a WIC participant, it must include all required information and must have been signed and dated by the health care provider no more than 30 days ago. Clinics cannot accept special food substitution prescriptions on Form #2 where the date has simply had a line drawn through it and a new date added. A new form must be submitted.

FP-293

GA WIC 2010 PROCEDURES MANUAL Page 1 of Referral Form (Form #2)

Attachment FP-39

FP-294

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-39 (cont'd)

Page 2 of Referral Form (Form #2)

FP-295

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-40

GEORGIA WIC APPROVED FOOD LIST CRITERIA TO EVALUATE AN ELIGIBLE FOOD ITEM

I.

Administrative Adjustments

A. A food company interested in participating in the Georgia WIC Program should submit product statewide availability, package size, unit cost per ounce and nutrient composition information to the Office of Nutrition* by October 1st of each year.

*Address: Office of Nutrition, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 30303-3142.

B.

A review of potentially new food items shall be conducted biennially. Consequently, the WIC

Approved Food List shall be printed biennially only. Biennial review of the WIC Food List does

not necessarily constitute a change in the food list. Changes to the WIC Approved Food List

shall occur more frequently only to accommodate Federal mandates.

C.

A product must be commercially available as a brand name, or a store brand, for a minimum of

twelve (12) consecutive months prior to October 1st of each year.

D. The food item cost cannot exceed 10 percent (10%) of the State average cost per ounce for that food group. Food groups include:

1.

Milk

2.

Eggs

3.

Cereal

4.

Infant Cereal

5.

Fish

6.

Cheese

7.

Juice

8.

Dried Beans/Peas and Peanut Butter

9.

Fruits and Vegetables

10. Whole Grains (bread, rice, tortillas)

E.

The food item must be acceptable to participants.

II. Nutrition Quality

A. Cereal - Adult

1.

Contains a minimum of 28 mg of iron per 100 gm of dry cereal.

2.

Contains not more than 21.1 grams of sucrose and other sugars per 100 grams of dry

cereal (less than 6 grams of sucrose and other sugars per ounce). At least one-half of the

total number of approved cereals must have whole grain as the primary ingredient and

meet labeling requirements for making a health claim as a "whole grain food with

moderate fat content."

3.

Contains not more than 500 mg of sodium per 1 ounce of dry cereal.

4.

Contains no artificial or non-nutritive sweeteners.

B.

Cereal - Infant

1.

Contains a minimum of 45 mg of iron per 100 gm of dry cereal.

2.

Contains no added sugar.

3.

Contains no added fruit.

4.

Contains no added formula

FP-296

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

C.

Milk

1.

Contains 400 IU Vitamin D per quart.

2.

Contains 2,000 IU Vitamin A per quart.

3.

Contains no added sugar or flavorings.

4.

No Buttermilk

D. Cheese Domestic Cheese (pasteurized, processed American, Monterey Jack, Colby, Natural Cheddar, Mozzarella, Swiss) Sliced Cheese (American, Cheddar, Swiss) String Cheese (Mozzarella String Cheese)

E.

Peanut Butter and Canned/ Dried Beans and Peas

1.

Including, but not limited to: black, navy, kidney, garbanzo, soy, pinto, great northern,

red, white, lima, black, broad, fava, cranberry, roman, and mung beans; crowder, cow,

split, black eyed and pigeon peas, chickpeas, and lentils.

2.

No flavored beans/peas allowed.

3.

No peanut butter and jelly, honey, marshmallow, or chocolate combinations.

F.

Juice

1.

Single strength or frozen concentrate or canned concentrate or pourable, 100% fruit juice

2.

30 mg vitamin C per 100 ml of reconstituted juice, minimum.

3.

Contains no added sugar.

4.

Calcium fortified juice allowed with counseling and CPA approval. See Attachment FP-

43 for distribution guidelines.

5.

No infant juices allowed.

G. Eggs Whole, large, grade A.

H. Fish Tuna or Salmon 100% tuna, water packed only. No albacore.

I.

Fruit and vegetables

Fresh, frozen or canned

Any variety of fresh whole or cut fruit without added sugar or artificial sweeteners Any variety of fresh whole or cut vegetable, except white potatoes without added, sugars, fats, and oils Any variety of canned fruits, including applesauce; juice-pack or water pack without added sugars, fats, oils, or salt Any variety of frozen fruits without added sugar Any variety of canned or frozen vegetable, except white potatoes, without added sugars, fats, oils

J.

Whole Grains

100% whole wheat bread or hamburger buns, brown rice, whole wheat or corn tortillas

K.

Soy milk -

1.

276 mg calcium per cup

2.

8 grams protein per cup

3.

500 IU vitamin A per cup

4.

100 IU vitamin D per cup

FP-297

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

5.

24 mg magnesium per cup

6.

222 mg phosphorous per cup

7.

349 mg potassium per cup

8.

0.44 mg riboflavin per cup

9.

1.1 mcg vitamin B12 per cup

III. Packaging

A. Food must be prepackaged, no bins except for fresh fruits and vegetables.

B.

Cereal (adult and infant)

1.

No single serving containers.

2.

Adult cereal weight must be in whole numbers, minimum of 11 ounces, not to exceed 36

ounces.

3.

Infant cereal only in eight (8) ounce packages.

C.

Cheese

1.

Brick or sliced cheese only, no shredded.

2.

Cheese from the dairy case only, no deli cheese.

3.

Plain cheese only, no additions of products such as jalapeno peppers.

4.

16 ounce package only

D. Juice

1.

No single serving containers.

2.

No fresh squeezed.

3.

Containers must be easily and clearly identified as fortified with 30 mg of vitamin C per

100 ml of juice, except orange juice and grapefruit juice.

4.

Forty-six or forty-eight (46-48) ounce containers, 64 ounce containers, 12 ounce frozen

cans, 12 ounce cans concentrate, or 11.5 oz pourable cans or 5.5 to 6 ounce can.

E.

Eggs

One dozen size carton only.

F.

Milk- (Cow)

1.

Half gallon and one gallon size: Whole, Reduced Fat (2%), Low-fat (1%), Lite (0.5%),

Skim (Non-Fat).

2.

Quart size containers only for Lactose Reduced and goat milk.

3.

Twelve ounce cans only for Evaporated milk and goat milk.

4.

Three quart boxes for Powder milk.

5.

8 ounce or half-pint box for ultra high temperature (UHT) milk.

Milk - (Meyenberg Goat Milk) Twelve ounce cans evaporated or quart
G. Tuna 5 ounce can only.

H. Salmon 6 oz or 14.75 oz only

I.

Peanut Butter

16 to 18 ounce container only.

FP-298

GA WIC 2010 PROCEDURES MANUAL

J.

Dried Beans/Peas

One pound bag or 14 to 16 ounce can.

Attachment FP-40 (cont'd)

IV. Formula

A. Complete Formula

1.

Iron fortified infant formula that contains at least 10 mg iron per liter of formula at

standard dilution.

2.

67 kcal per milliliter (approximately 20 kcal per fluid ounce at standard dilution).

B.

Formula Not Meeting the Requirements for a Complete Formula

1.

Formula intended for use as an oral feeding and prescribed by a physician when the

participant has a medical condition that precludes the use of conventional formula or

food.

2.

Allow supplements to be used in conjunction with an appropriate prorated food

package. Substitute a specified amount of supplement per quart or can of milk or

formula.

FP-299

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-41

FP-300

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-41 (cont'd)

FP-301

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-41 (cont'd)

FP-302

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-41 (cont'd)

FP-303

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-42

Formula Type: ___________________________

Formula Tracking Log

Returned formula & Free Trade Formula

Date:

Action Taken
Received "R" Issued "I"
Destroyed "D"

*Number of Cans
Powder Concentrate RTF

Client's Name
AND / OR
Client's WIC ID #

Reason for Receiving, Issuing or Discarding Formula

Balance Forward
R I D

Signature & Title of CPA

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

Inventory Total

Notes:

*Cases must be converted to cans **Inventory verification must be completed at least quarterly.

FP-304

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-43

Calcium Fortified Juices
Calcium-fortified Juices Guidelines, Procedures & Recommendations Calcium-fortified juice that meets the minimum Federal requirements for a WIC eligible juice (100 percent fruit/vegetable juice that contains 30 milligrams of vitamin C per 100 milliliters of juice) is WIC eligible. It may be used for the fruit/vegetable juice component of the WIC food packages up to the maximum quantities for juice. WIC State agencies have the option of approving calciumfortified juice for inclusion on their lists of approved WIC juices, as they do with other WIC eligible foods. State agencies are encouraged to develop policies and procedures for local agencies to follow when issuing calcium-fortified juice.
Juice, including calcium-fortified juice, cannot be prescribed as a substitute for the dairy products in WIC Food Packages. Calcium-fortified juice also should not be offered routinely to all WIC women and children participants. It should be prescribed only to address specific nutritional need of individuals, whose dietary intake of calcium-rich food products is low due to reasons such as cultural food preferences, dislike of milk, or lactose intolerance.
The 2004-2006 Georgia WIC Approved Food List will remove calcium-fortified juice from the INELIGIBLE ITEMS. But it will additionally not be highlighted as a juice on the approved food list. If the CPA determines a possible benefit to include calcium-fortified juice in the food package, that client can be instructed to purchase calcium-fortified juices. The vendor manual and training will indicate calcium-fortified juices that meet federal regulation above may be included in any food package (types, least expensive where appropriate, and container sizes all apply). Calcium-fortified juices are currently available in limited flavors and package sizes.
Counseling Recommendations: 1. If clients have never tried calcium-fortified juices, recommend they try just one container of calcium-fortified juice to see if they like the taste. Some have found this to be bitter compared to the `regular' juices. 2. Provide counseling on other sources of calcium as part of the nutrition education session along with handouts.
The calcium-fortified juices can be purchased with any of the existing child and adult packages, but this is to be recommended secondary to the client assessment. We are not promoting this as a dairy alternative, but merely making it available as an option as deemed appropriate.

FP-305

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

999 Single Item Voucher Codes

W5 = Prenatal/Mostly Breastfeeding Women W6 = Non-Breastfeeding Postpartum/Some Breastfeeding Woman W7 = Exclusively Breastfeeding Women/Prenatal with Multiples/
Mostly Breastfeeding Multiples C1 = Child 12-23 months old C2 = Child >23 months old I = Infant

Voucher code 775 703 778
273
A02
A03 A04 779 780 A05 782 A07
781
A08
A09
783 A10 772
771

Eggs: Eggs: Juice
Juice:
Juice:
Juice: Juice: Cereal: Cereal: Cereal: Beans: Peanut Butter: Beans or peanut butter Whole Grains: Whole Grains:
Fish: Fish: Milk:
Milk:

Supplemental Foods Voucher message 2 dozen Least expensive brand 1 dozen Least expensive brand 1-46 oz container or 1-12 oz can frozen or 11.5 oz can pourable 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable 3 containers (46 to 48 oz) or 3-12 oz cans frozen or 3-11.5 oz cans pourable 2-64 oz containers 1-64 oz container No more than 24 oz No more than 36 oz No more than 18 oz 1 lb dried or 4 cans (14 to 16 oz) 1 container (16-18 oz)
1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter Pick 2: 16 oz bread; 16 oz brown rice; 16 oz tortilla; or 14 to 16 oz bun Pick 1: 16 oz (bread, or brown rice or whole grain tortilla) or 14 to 16 oz bun No more than 30 ounces No more than 15 ounces 1 gallon low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand 2 gallons low-fat (fat-free, 1%, 2%) No whole milk Least expensive

Allowed Category W7
W5, W6, W7, C1, C2 W5, W6, W7
W5, W6, W7
W5, W7
C1, C2 C1,C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C2
W6, C2
C1, C2
W5, W6, C1, C2
W7 W7 W5, W6, W7, C2
W5, W6, W7, C2

FP-306

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

Voucher code 774 786
785
A11 A12 205 A13 A14 A15 A16 A17
A18
A19 A20 773 776 A01 A21

Cheese: Milk:
Milk:
Tofu: Tofu: Infant Cereal: Infant Cereal: Dry Milk Dry Milk Dry Milk Milk
Milk
Milk
Milk
Cheese Juice
Milk
Milk

Supplemental Foods Voucher message brand 1-16 oz package 1 gallon or 4 quarts or 2 half gallons low-fat (fat-free, 1%, 2%) Lactose free, Acidophilus, or Acidophilus and Bifidum. No whole milk Least expensive brand 2 quarts or 1 half gallon low-fat (fatfree, 1%, 2%) Lactose free, Acidophilus, or Acidophilus and Bifidum. No whole milk Least expensive brand 4 pounds 1 pound 1-8 oz container

Allowed Category W5, W6, W7, C1, C2
W5, W6, W7, C2
W5, W6, W7, C2
W5, W6, W7, C1, C2 W5, W6, W7, C1, C2
I, C1, C2

3-8 oz containers

I, C1, C2

1-3 quart box non-fat dry powder Least expensive brand 2-3 quart boxes non-fat dry powder Least expensive brand 3-3 quart boxes non-fat dry powder Least expensive brand 4-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand 1-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand 4-12 ounce cans evaporated (whole) Least expensive brand 1-12 ounce cans evaporated (whole) Least expensive brand 2-16 oz packages 4 containers (46 to 48 oz) or 4-12 oz cans frozen or 4-11.5 oz cans pourable 1 gallon Whole milk Only Least expensive brand 2 gallons Whole milk Only Least expensive brand

W5, W6, W7, C2 W5, W6, W7, C2 W5, W6, W7, C2 W5, W6, W7, C2
W5, W6, W7, C2
W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W7 (EBF twins only) W5, W6, W7, C1, C2 W5, W6, W7, C1, C2

FP-307

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

Voucher code A34
A22
A23
A24
A25
A26
A27
A28
A30
Prenatal Conversion to an Exclusively Breastfeeding Package
A37
P05
Prenatal Conversion to an Exclusively Breastfeeding Package

Milk Goat Milk Goat Milk Goat Milk Goat Milk Goat Milk
Milk
Milk Milk:

Supplemental Foods Voucher message 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 4 quarts low-fat goat milk No whole milk 8 quarts low-fat goat milk No whole milk 1 quart low-fat goat milk No whole milk 4 quarts whole goat milk or 5-12 oz cans evaporated goat milk No lowfat milk 1 quart whole goat milk or 1-12 oz can evaporated goat milk No low-fat milk 1 quart low-fat (fat-free, 1%, 2%) Lactose free, Acidophilus, or Acidophilus and Bifidum. No whole milk Least expensive brand 1 quart Whole Lactose free, Acidophilus, or Acidophilus and Bifidum. Least expensive brand 1 gallon low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand

Eggs: 1 dozen

Fish: Infant Cereal: Produce:

No more than 30 oz 4-8 oz container
$2 for fresh, frozen, or canned fruit and vegetables (No potatoes except for sweet potato or yams; no products with added sugar, seasonings, fat, or oils, no creamed vegetables, no stewed or diced tomatoes

Allowed Category W5, W6, W7, C2 W5, W6, W7, C2 W5, W6, W7, C2 W5, W6, W7, C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C2
W5, W6, W7, C1, C2 W7
C1, C2 W7

FP-308

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

Voucher code 134 145 146 147 151 185 186 187 192 374 518 544 707 874 358 359 553 116 117 307 308 590

Infant/Special Formulas Voucher message Formula 1-12.9 oz can powder Isomil Advance Formula 1-13 oz can concentrate Isomil
Advance Formula 2-13 oz cans concentrate Isomil
Advance Formula 3-13 oz cans concentrate Isomil
Advance Formula 1-22 oz can powder Similac Go and
Grow EarlyShield Milk Based Formula 1-13 oz can concentrate Similac
Advance EarlyShield Formula 2-13 oz cans concentrate Similac
Advance EarlyShield Formula 3-13 oz cans concentrate Similac
Advance EarlyShield Formula 1-22 oz can powder Similac Go and
Grow Soy Based Formula 1-12.9 oz can powder Similac
Sensitive Formula 1-32 oz container ready to feed
Similac NeoSure Formula 1-32 oz container ready to feed
EnfaCare LIPIL Formula 1-400 gram (14.1oz) can powder
Nutramigen AA LIPIL Formula 1-12.9 oz can powder Similac
Advance EarlyShield Formula 1-1 lb can powder Alimentum Formula 1-32 oz container ready to feed
Alimentum Formula 1-8 oz container ready to feed Boost Formula 1-8 oz container ready to feed Bright
Beginnings Soy Pediatric Drink Formula 6-8 oz containers ready to feed Bright
Beginnings Soy Pediatric Drink Formula 1-12.9 oz can powder Enfamil AR
LIPIL Formula 1-32 oz container ready to feed
Enfamil AR LIPIL Formula 6-2 oz containers ready to feed

Allowed Category I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2
W5, W6, W7 C1, C2 C1, C2 I, C1, C2 I, C1, C2 I, C1, C2

FP-309

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

Voucher code 591 305
306
301 303 310 121 255 474 475 476 477 157 159 563 557 558 716 717

Infant/Special Formulas Voucher message
EnfaCare LIPIL Formula 1-12.8 can powder EnfaCare LIPIL Formula 6-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (1-6 pack) Formula 6-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (1-6 pack) Formula 1-8 oz container ready to feed Ensure Formula 1-8 oz container ready to feed Ensure Fiber Formula 1-237 ml container EO28 Splash Formula 1-32 oz container ready to feed Isomil Advance Formula 1-8 oz container ready to feed Isomil Advance Formula 1-400 gram (14.1 oz) can powder Neocate Junior Formula 1-60 gram packet powder Neocate One+ Formula 1-12.9 oz can powder Nestle Good Start Soy PLUS Formula 1-13 oz can concentrate Nestle Good Start Soy PLUS Formula 1-12.6 oz can powder Nutramigen LIPIL with Enflora LGG Formula 1-13 oz can concentrate Nutramigen LIPIL Formula 1-250 ml container ready to feed Nutren 2.0 Formula 1-250 ml container ready to feed Nutren Junior Formula 1-250 ml container ready to feed Nutren Junior Fiber Formula 1-8 oz container ready to feed Pediasure Formula 6-8 oz container ready to feed Pediasure

Allowed Category I, C1, C2 I, C1, C2
I, C1, C2
W5, W6, W7 W5, W6, W7
C1, C2 I, C1, C2 I, C1, C2 C1, C2 C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 W5, W6, W7 C1, C2 C1, C2 C1, C2 C1, C2

FP-310

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

Voucher code 720 721 479 480 578 259 141 256 892 245 246 481 482 483 101 363 484 588
587
586

Infant/Special Formulas Voucher message Formula 1-8 oz container ready to feed
Pediasure with Fiber Formula 6-8 oz container ready to feed
Pediasure with Fiber Formula 1-250 ml container ready to feed
Peptamen Formula 1-250 ml container ready to feed
Peptamen Junior Formula 1-250 ml container ready to feed
Peptamen Junior with Prebio Formula 1-1 lb can powder Portagen Formula 1-1 lb can powder Pregestimil LIPIL Formula 1-13 oz can concentrate ProSobee
LIPIL or Enfamil Soy LIPIL Formula 1-12.9 oz can powder ProSobee LIPIL
or Enfamil Soy LIPIL Formula 1-32 oz container ready to feed
Similac Advance EarlyShield Formula 1-8 oz container ready to feed
Similac Advance EarlyShield Formula 4-2 oz containers ready to feed iron
fortified Similac NeoSure (1-4 pack) Formula 1-12.8 oz can powder Similac NeoSure Formula 1-14.1 oz can powder Similac PM
60/40 Formula 1-32 oz container ready to feed
Similac Sensitive Formula 1-13 oz can concentrate Similac
Sensitive Formula 1-32 oz container ready to feed
Similac Sensitive RS Formula 4-2 oz containers ready to feed iron
fortified Similac Special Care 20 (1-4 pack) Formula 4-2 oz containers ready to feed iron fortified Similac Special Care 24 (1-4 pack) Formula 4-2 oz containers ready to feed iron fortified Similac Special Care 30 (1-4 pack)

Allowed Category C1, C2 C1, C2
W5, W6, W7 C1, C2 C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2
I, C1, C2
I, C1, C2

FP-311

GA WIC 2010 PROCEDURES MANUAL

Attachment FP-44

Voucher code 511
512
530
531
535 536 551
552
582 583

Modulars Voucher message Formula 1-400 gram (14.1 oz) can powder
Duocal Formula 4-400 gram (14.1 oz) cans powder
Duocal (1 case) Formula 1 carton (50 packs per carton)
Similac Human Milk Fortifier Formula 1 case (150 packs per case)
Similac Human Milk Fortifier Formula 1-12.3 oz can Polycose Formula 6-12.3 oz cans Polycose (1 case) Formula 1 carton (100-0.71 gram sachets per
carton) Enfamil Human Milk Fortifier Formula 1 case (200-0.71 gram sachets per
carton) Enfamil Human Milk Fortifier Formula 1-32 oz container MCT Oil Formula 6-32 oz containers MCT Oil (1 case)

Allowed Category All
All
C1, I
C1, I
All All I, C1
I, C1
All All

FP-312

GA WIC 2010 PROCEDURES MANUAL

Nutrition Education

TABLE OF CONTENTS

Page

I.

Purpose.................................................................................................................... NE-1

II.

Definition................................................................................................................. NE-1

III. Goals ........................................................................................................................ NE-1

IV. State Agency ........................................................................................................... NE-2

A. State Nutrition Staff ......................................................................................... NE-2

B. State Nutrition Education Responsibilities .................................................. NE-2

V.

Local Agency .......................................................................................................... NE-3

A. Local Nutrition Staff ........................................................................................ NE-3

B. Local Nutrition Education Responsibilities ................................................. NE-4

C. Training ............................................................................................................. NE-5

VI. Participant Nutrition Education .......................................................................... NE-7

A. Participant Nutrition Education Requirements........................................... NE-7

B. Documentation of Nutrition Education........................................................ NE-9

VII. Participant Referral to Other Agencies ............................................................. NE-10

A. Participant Referrals ...................................................................................... NE-10

B. Participant Documentation........................................................................... NE-11

VIII. Nutrition Education Materials ........................................................................... NE-11

A. Criteria for Development and Use .............................................................. NE-11

Attachments: NE-1 WIC Maternal High Risk Criteria ...................................................................... NE-13 NE-2 WIC High Risk Criteria for Infants and Children ........................................... NE-14 NE-3 Guidelines for Nutrition Assistant Training.................................................... NE-15

GA WIC 2010 PROCEDURES MANUAL

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NE-4 SOAP Note Documentation Format.................................................................. NE-20 NE-5 Material Evaluation Form................................................................................... NE-21 NE-6 WIC Local Agency Continuing Education Documentation Log................... NE-26

GA WIC 2010 PROCEDURES MANUAL

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I. PURPOSE
A. This section of the Georgia WIC Program Procedures Manual defines the concept of nutrition education; states the goals for nutrition education; and explains the requirements for providing nutrition education to WIC participants.

B. Nutrition education shall be considered a Georgia WIC Program benefit, and made available at no cost to all participants.

II. DEFINITION
"Nutrition Education" is a dynamic process delivered through individual or group sessions and the provision of materials by which participants gain the understanding, skills, and motivation necessary to promote and protect their nutritional well being through their food, physical activity, and behavioral choices. Nutrition education shall be focused on the participant's interests and designed based on ethnic, cultural, and geographic preferences and with consideration for language, educational, and environmental factors. The implementation of Value Enhanced Nutrition Assessment (VENA) will make this process more effective for both participants and Competent Professional Authorities (CPA) by providing more opportunities for client centered dialogue. The intent of VENA is to complement nutrition assessment, education and counseling, which will lead to a more measurable method of client centered goal setting.
III. GOALS
Nutrition education for WIC participants is designed to achieve two broad goals:
A. Emphasize the relationship between proper nutrition, physical activity, and good health; with emphasis on the nutritional needs of pregnant, breastfeeding and postpartum non-breastfeeding women, infants, and children less than five (5) years of age.
B. Assist the individual who is at nutritional risk in achieving positive changes in food and physical activity behaviors, in order to improve nutritional status and to prevent nutrition-related problems, through the optimal use of supplemental foods and other nutritious foods.

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IV. STATE AGENCY
A. State Nutrition Staff
The delegation of WIC nutrition education activities is vested within the Georgia Department of Community Health, Division of Public Health, Birth Outcomes, and Office of Nutrition.
The nutrition services component of the WIC Program is carried out under the direction of a qualified nutritionist (graduate level degree, and a registered dietitian, or eligible for registration as a dietitian). The responsibilities of this person are to plan, direct, and coordinate the nutrition education component of the WIC Program.
Nutrition program consultants in the Office of Nutrition are available to local agencies as a resource in order to facilitate the State's efforts to strengthen and integrate Maternal and Child Health services (MCH) and WIC nutrition services. Current staff assignments are available from the Office of Nutrition.
B. State Nutrition Education Responsibilities
The State agency responsibilities for nutrition education: 1. Develop, implement, and evaluate the State Nutrition Education
Plan. Periodically review, and evaluate, and make appropriate revisions as necessary.
2. Develop guidelines for local agency Nutrition Education Plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency Nutrition Education Plans on a periodic basis through on-site visits and annual reporting.
4. Evaluate the nutrition services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for WIC competent professional authorities (CPA's) and nutrition assistant staff at local clinics. Training and technical assistance provides WIC competent professional authorities with current information on the nutritional management of normal and high-risk participants, special problems, and emerging issues in nutrition.

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6. Identify and develop resource and education materials for use at local agencies. Provide materials in languages other than English in areas where a substantial number of participants are non-English speaking.
7. Coordinate WIC nutrition education activities with related programs and professional groups such as the Cooperative Extension Service, Food Stamp Program, professional organizations, advisory committees, etc.
8. Develop and implement procedures to assure that nutrition education is provided to all adult participants, child participants whenever possible, and to parents or caretakers of infant or child participants.
9. Perform and document evaluation of nutrition education activities on an annual basis. The evaluation shall include an assessment of participant's views concerning the effectiveness of the nutrition education they received.
10. Establish standards for participant contacts that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.

V. LOCAL AGENCY
A. Local Nutrition Staff
1. Each of the WIC local agencies must be staffed with a minimum of one (1) public health nutritionist in the class of Nutrition Services Director, Nutrition Program Manager, or Nutrition Manager. This nutritionist will be designated as the District Nutrition Coordinator. Duties include: planning, organizing, implementing, and evaluating the nutrition service component of the WIC Program. This encompasses development and approval of nutrition education materials, development of the nutrition education plan, and implementation of nutrition risk criteria.

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2. Each WIC local agency must be staffed with a minimum of one (1) Competent Professional Authority (CPA) for every one thousand (1,000) participants, and one (1) Registered Dietitian (RD) for every five thousand (5,000) participants.
3. Nutrition positions should be appropriately classified according to the Performance Plus class specifications for nutrition personnel. The Performance Plus Nutritionist class specifications should be used for nutritionists providing direct client nutrition services, and these nutritionists should receive supervision from a higher level public health nutritionist.
4. The Performance Plus class specifications for nutrition personnel and qualifications and compensation levels are available on request from the Georgia Merit System of Personnel Administration.

B. Local Nutrition Education Responsibilities
The local agencies shall perform the following activities in carrying out their nutrition education responsibilities: 1. Provide nutrition education to all adult participants, parents or
caretakers of infant or child participants, and whenever possible, to child participants. Program participants may be encouraged to assist in providing nutrition education to other participants (e.g. the use of a breastfeeding participant to talk with participants who are interested in breastfeeding). Individual or group sessions and/or education materials designed for program participants may be utilized for the delivery of nutrition education services to non-participating women, infants, and children who take part in other local agency health services.
2. Provide in-service training and technical assistance for competent professional authorities (CPA's) and nutrition assistants at local clinics.
3. Develop a Nutrition Education Plan consistent with the nutrition education portion of the State Plan.
4. Develop a system and/or utilize annual public comment responses for the regular assessment of participant views on nutrition education and breastfeeding promotion, at least on an

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annual basis. This data shall be used in the development and revision of the Nutrition Education Plan. The findings shall be reported annually in the Nutrition Education Plan that is due to the Office of Nutrition (end of March).

C. Training
1. Orientation
a. The WIC CPA must receive training on anthropometric and hematological measurements, nutrition risk assessment, and food package assignments prior to being assigned to certify WIC participants (e.g. WIC 101).
b. The WIC CPA must also receive competency based nutrition skills within 24 months of employment. This training should cover nutritional management of normal and high-risk perinatal women, infants, children, and adolescents; and breastfeeding management in normal and special situations.
2. Continuing Education
a. All WIC CPA staff must receive at least twelve (12) hours of nutrition specific continuing education each year. Training must be approved by the local agency Nutrition Services Director (or designee). The twelve hours of nutrition specific continuing education can be met in the following ways: (1) Through participation at local, state, or national workshops or meetings to develop and update skills and knowledge in nutrition and lactation management; (2) Through completion of Internet based or home study nutrition related educational courses (developed and/or approved by a nationally recognized professional organization); (3) Establishment of a staff Nutrition Journal Club, where peer reviewed nutrition related research articles are shared, reviewed and discussed. A maximum of one (1) credit hour (or clock hour) will be allowed per meeting time. Examples of approved peer reviewed research journals include: Journal of the American Dietetic Association, the

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American Journal of Public Health and Journal of Nutrition Education and Behavior, etc. (4) Special Note: With the implementation of the Value Enhanced Nutrition Education (VENA) initiative, continuing education training received annually by the CPA's and other WIC staff, should address their identified training needs and in addition must include one or more of the following areas:
i. Competency based trainings in nutrition assessment, education and counseling (including critical thinking, motivational interviewing, reflective listening, rapport building, and goal setting) and breastfeeding education.
ii. In addition, update trainings on WIC programmatic content areas (e.g. risk criteria, food package/approved foods, etc.) should be included.
b. All nutrition training and continuing education activities conducted or attended by the local staff must be recorded and kept on file by the local agency.
3. Reporting and Monitoring
a. The WIC Local Agency Continuing Education Documentation Log (Attachment NE-6) should reflect training obtained by all CPAs in the local agency, be maintained in the local agency files, and must be available for review by State Office of Nutrition staff during the WIC program review.
b. The file should include the following at a minimum for each CPA in the local agency: (1) CPA name and title; (2) Clinic number(s); (3) Yearly total of continuing education hours received.
c. Local agency training provided must include at a minimum: (1) Training topics; (2) Agendas; (3) Speaker(s) vitae (must show evidence of training in the area which they are presenting); (4) Staff trained (e.g. all CPA staff, Nutritionists only, etc.);

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(5) Sign-in roster; (6) Certificate of Attendance (indicating education hours to be
awarded).

VI. PARTICIPANT NUTRITION EDUCATION
A. Participant Nutrition Education Requirements
1. All adult participants and caretakers of child participants must be provided with two (2) nutrition education contacts (must receive nutrition education on two different occasions) during each six (6) month certification period, but not within the same day/clinic visit. For prenatal women and parents/caretakers of infant participants certified for a period in excess of six (6) months, nutrition education contacts shall be made available at a quarterly rate, but not necessarily taking place within each quarter. Participants must be encouraged to attend and participate in nutrition education activities, but cannot be denied supplemental foods for failure to attend or participate in the provided activities.
2. The nutrition education contacts shall be made available through individual or group sessions, which are appropriate to the individual participant's nutritional needs.
3. A local agency must submit proposals for the development of new nutrition education projects and must contact the Office of Nutrition for technical assistance prior to initiating the implementation of a nutrition education program or strategy that is not conducted through individual or group, face-to-face sessions. Any non-direct nutrition education session, for example, Internet, self-direct computer module, etc. must be approved prior to implementation. Upon receipt of the local agency request, the Office of Nutrition staff will review the proposed nutrition education program/strategy and provide the local agency with initial feed back within thirty (30) days. Office of Nutrition approval of proposed special projects will be provided to the WIC Branch within sixty (60) days of receipt of the final local agency proposal. If USDA approval is required, the Office of Nutrition and the WIC Branch will assist the local agency in obtaining the approval.

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4. All participants shall receive at least one nutrition education contact during each certification period which relates to their own (or their child's) dietary practices, as assessed by the CPA, from the State approved Nutrition Assessment Questionnaire. Visual aids, such as food models or measuring cups, should be used to obtain a good assessment of dietary practices and to help the participant learn about portion sizes.
5. Counseling with regard to the need for regular physical activity may be documented as nutrition education, since physical activity relates to energy balance, and thus contributes to nutritional status. Encouragement to decrease physical inactivity and screen time should be provided.
6. All high-risk WIC participants (as defined in Attachment NE-1 and NE-2) must be scheduled to receive a high-risk nutrition education contact during the current certification period. The High Risk Nutrition Education contact must include a care plan. Refer to Attachment NE-4 for the documentation components of the care plan.
7. All women participants must receive exit counseling by the final nutrition education contact of the postpartum period. Exit counseling is defined as counseling which includes the following topics which are to be discussed within the valid certification period: a. Importance of folic acid intake
b. Health risks of using alcohol, tobacco, and other drugs
c. Continued breastfeeding as the preferred method of infant feeding (for those women who are breastfeeding)
d. Importance of up-to-date immunizations
8. Parents or caretakers of WIC infants and children must also be provided with preventive information about abuse of drugs and other harmful substances.
9. Each local agency must have an established nutrition reference guide available. Examples of approved nutrition reference guides include, but are not limited to:

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a. ADA Nutrition Care Manual b. Georgia Dietetic Association Nutrition Manual
10. Nutrition education contacts must be provided by a nutritionist, Registered Dietitian (RD), or other Competent Professional Authority (CPA) that has been trained by the State or local agency. Nutrition Assistants can provide low-risk nutrition education contacts when appropriate nutrition education training has been received. The Office of Nutrition must approve the training plan. (See Attachment NE-3 for the Guidelines for Nutrition Assistant Training and list of items to be submitted for approval).
11. A class outline must be developed when group-facilitated classes are used to provide the nutrition education contact. Class outlines must be kept at the clinic site for use by clinic staff and provided to the Office of Nutrition at the time of program reviews.
12. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing secondary nutrition education contacts.

B. Documentation of Nutrition Education
1. All individual nutrition education services and contacts received by participants must be documented in the participant's health record.
a. In order to facilitate continuity of care, specific aspects of nutrition counseling must be documented (e.g., introduction of solids; portion sizes for the 2-3 year old; ways to increase fluid intake).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
2. Group nutrition education contacts must be documented in the participant's health record and should be validated with the

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participant's signature on a class attendance sheet, which contains the group-facilitated class objective(s) and the original signature of the staff conducting the group-facilitated class. A description of the district's method of documentation must be submitted for approval prior to implementation.
3. Documentation of nutrition education contacts must include the date, topic(s), care plan (if high risk), the title of the person providing the nutrition education, and method by which the nutrition education contact was provided (e.g., class, kiosk, individual counseling, etc.).
4. Missed appointments for nutrition education contacts and the refusal of a participant/caregiver to receive nutrition education must be documented in the participant's health record. However, failed, missed and refused secondary nutrition education appointments do not count as having provided secondary nutrition education.

VII. PARTICIPANT REFERRAL TO OTHER AGENCIES
Participants must be assessed for referrals during each certification appointment.
A. Participant Referrals
1. Participants must be referred to the Food Stamp Program, Medicaid and Temporary Assistance for Needy Families (TANF). Participants shall be informed of these programs and, if needed, be provided with the addresses and telephone numbers of local/State offices.
2. Local agencies are encouraged to coordinate with and refer participants to the Cooperative Extension Service, Expanded Food and Nutrition Education Program (EFNEP).
3. Local agencies should refer participants to other health services offered within the health department system and other agencies and services. These include, but are not limited to:

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Maternal Health Programs
High Risk Pregnancy Program Family Planning Program Sexually Transmitted Disease
Assistance Programs
Food Stamps Medicaid Right from the Start Temporary Assistance for
Needy Families (TANF) Headstart

Child Health Programs
Children 1st Children's Medical Services Immunization Program Lead Screening Program Health Check Dental Health Program
Community Resources
AIDS Program Private Physician Mental Health and Substance Abuse Program

4. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program. General breastfeeding referrals should be documented as "W,"while referrals to breastfeeding peer counselors should be documented as "X."

5. Any participant identified as high risk should be referred to the nutritionist or registered dietitian (V).

B. Participant Documentation
Referrals to and enrollment in other health services and programs must be documented in the participant's health record. A decision not to refer or a refusal by the participant must also be documented.

VIII. NUTRITION EDUCATION MATERIALS
A. Criteria for Development and Use
1. All nutrition education materials and forms used and developed locally for WIC participants must be approved by the District Nutrition Coordinator or designee. See Materials Evaluation Form for guidance (Attachment NE-5). The Office of Nutrition is

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available for consultation and technical assistance to review nutrition education materials.
2. Sample copies of all nutrition education materials used by the local agency must be made available to the Office of Nutrition during the program review.
3. All nutrition education materials used must accurately reflect current documented scientific knowledge of nutrition.
4. Materials must be prepared to meet needs of the specific population group to be served, including migrant farm workers and homeless persons. Consideration must be given to the reading level as well as to the cultural and language needs of clients.
5. The Office of Nutrition reserves the right to disapprove the use of nutrition education materials if it determines them to be inappropriate.
6. If a local agency develops materials that are applicable statewide, the Office of Nutrition may seek approval from the local agency to duplicate these materials.

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Attachment NE-1

WIC MATERNAL HIGH RISK CRITERIA

Any WIC prenatal, breastfeeding, or non-breastfeeding woman who has the following high-risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their nutritional practices, as reflected in an individual care plan. In most instances, a nutritionist should provide this counseling. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria
Hemoglobin or hematocrit at treatment level
Pre-pregnancy/postpartum underweight (>10% below midpoint of normal weight for height range OR Body Mass Index <19.8)

Risk Code 201
101, 102

Pre-pregnancy/postpartum obesity (>36% above mid-point of normal weight for height range OR Body Mass Index >29)

111, 112

Low maternal weight gain or weight loss during pregnancy
Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or health professional acting under standing orders of a physician
EDC or delivery prior to 17th birthday
Blood lead level > 10 Pg/dl
Breastfeeding (BF) complications; referral to appropriate BF counselor must be made
Hyperemesis Gravidarum
Gestational diabetes or history of gestational diabetes
Multifetal gestation
Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

131, 132 341-349
and 351-362
331 211 602
301 302, 303
335

Appendix
B-1
C-1 Weight for
Height Table;
C-2 Body Mass Index Table; C-3 BMI Chart
C-1 Weight for Height Table; C-2 Body Mass Index Table; C-3 BMI Chart

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Attachment NE-2

WIC HIGH-RISK CRITERIA FOR INFANTS AND CHILDREN
WIC infants and children who have the following high-risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their nutritional practices, as reflected in an individual care plan. A nutritionist, in most instances, should provide this counseling. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria Hemoglobin or hematocrit at treatment level
Underweight (weight for length/height <5th %)
Overweight (weight for length/height > 95th %) May only be used for children as high-risk criteria.
Short stature (length/height for age <5th %)

Risk Code 201 103 113
121

Failure to thrive; inadequate growth

134 and/or 135

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet or special prescribed formula as ordered by a physician or health professional acting under standing orders of a physician

341-360; 362; 382

Low birth weight infant [infant weighing 2500 grams (5

141

pounds) or less at birth]. May only be used for infants only

as high-risk criteria.

Blood lead level > 10Pg/dl

211

Fetal Alcohol Syndrome

382

Breastfeeding complications; infants only; referral to

603

appropriate breastfeeding counselor must be made

Any condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required

Appendix B-2

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Attachment NE-3

GUIDELINES FOR NUTRITION ASSISTANT TRAINING I. Qualifications for Nutrition Assistants
Who can be trained: A. WIC clerical staff and health services technicians.

B. Expanded Food and Nutrition Education Program (EFNEP) agents.

C. Volunteers with a background in Home Economics, Nutrition, Medical Science, and Health Education.

D. Nursing students who have taken at least one (1) nutrition course. E. University students who have done nutrition/health course work. F. Dietetic interns.

II. Who can provide Nutrition Assistant Training
A nutritionist, registered dietitian, or other Competent Professional Authority that has been trained by the State or local agency. Certified Nutrition Assistants may assist the facilitator to provide peer experiences and support.

III. Competencies for Nutrition Assistants
A. Basic WIC Program Knowledge. The WIC Nutrition Assistant will be able to: 1. Describe the basic goal of the WIC Program.
2. List eligibility requirements for the WIC Program.
3. Name the State and Federal agencies that fund and administer the WIC Program.
4. Identify the district WIC staff, including the Nutrition Services Director or the Nutrition Program Manager, and where to locate the district WIC office (address and phone number).
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Attachment NE-3 (cont'd)

5. Locate: (a) the local WIC clinic policies and procedures; (b) list of local area WIC vendors; (c) USDA rules and regulations or Georgia WIC Program Procedures Manual policies relating to supplemental foods and nutrition education.
6. Describe the process of how a WIC participant obtains WIC foods.
List the various WIC approved foods.
List notification requirements.
7. Demonstrate a thorough knowledge of individual class outlines and content, as outlined by the district nutrition coordinator/designee. The nutrition assistant should score ninety (90) percent or above on the written test.

B. Communication Skills. The Nutrition Assistant will be able to: 1. Demonstrate each of the following factors in a participant interview or group-facilitated class:
- Making introductions - Explaining purpose of class/contact - Working within a given time frame - Reflective Listening - Using open-ended questions - Being non-judgmental - Using simple language - Conveying sincere interest - Conveying positive body language and attitude
2. Identify problems, during the individual contact or groupfacilitated class, which are WIC, health, or staff-participant relationship oriented.

C. Referral Skills. The Nutrition Assistant will be able to: 1. Refer problems encountered during the group-facilitated class/individual contact to appropriate personnel.
2. Refer medical and nutrition related problems to the appropriate professional, as written in the class outlines.

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Attachment NE-3 (cont'd)

IV. Requirements for Training/Continuing Education
Low-risk secondary nutrition education contacts can be provided within the following parameters:
A. A training session must be completed,

B. The test and clinic observation must be completed for each topic area, and

C. Nutrition information given to participants must be limited to that received in the training sessions (topic area) by the nutrition assistant.

Nutrition Assistants must receive at least twelve (12) hours of continuing education per year. Training must be approved by the local Nutrition Services Director (or designee). These hours can be attained through:
1. Participation in local agency Nutrition Assistant trainings
2. Other nutrition conferences/workshops/training

V. Parameters for Nutrition Assistants
Nutrition Assistants will be trained to provide very specific and limited nutrition information to WIC participants. Information will be limited to that learned in training. Referrals to the nutritionist will be made based on guidance in class outlines and/or the training manual, and/or for questions beyond the scope of the training received by the nutrition assistant.
VI. Evaluation Component
Evaluation of the nutrition assistant includes the following: A. The nutrition assistant must score 90% or above on a test for each topic
area, before being able to proceed to the next step.
B. The nutrition assistant must observe a professional providing low-risk secondary nutrition education contacts for at least one (1) clinic day, before being able to provide these her/himself.
C. The nutrition assistant must be observed conducting at least three (3) low-

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Attachment NE-3 (cont'd)

risk secondary nutrition education contacts before being able to do so routinely.

D. The immediate supervisor must be readily accessible to assist the nutrition assistant with problems.

E. The Nutrition Services Director (or designee) will conduct quarterly record reviews, where applicable, and observe the nutrition assistant providing low-risk secondary nutrition education contacts.

F. The Nutrition Services Director (or designee) will be available to provide technical supervision and to act as a resource.

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Attachment NE-3 (cont'd)

NUTRITION ASSISTANT TRAINING PLAN CHECKLIST FOR ITEMS TO SUBMIT FOR APPROVAL
Training Plan:
Class Outlines for use in training nutrition assistants, including post-tests.
Note: These may be submitted on an on-going basis.
Evaluation Component
Plan for nutrition assistant to observe professional(s) providing low-risk secondary nutrition contacts.
Plan for nutrition coordinator (or designee) to observe nutrition assistant(s) providing low-risk secondary nutrition education contacts.
Plan to conduct quarterly chart reviews , where applicable, and observation of nutrition assistant(s).
Class Outlines for use by nutrition assistant(s) in providing low-risk secondary nutrition education contacts group-facilitated class or individual counseling.
Documentation Procedures to be used by nutrition assistants.

Additional Information:
Name(s) of nutrition assistant(s) being trained, and clinic(s) in which trainee is working.
Name(s) of direct supervisor(s).
Name of district nutritionist designated to provide technical assistance.

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Attachment NE-4

SOAP NOTE DOCUMENTATION FORMAT

Once the nutritional status of an individual has been determined, the assessment of the problem and intervention plans need to be communicated to other health professionals. The use of the SOAP Note format is an excellent way of conveying this nutritional information. The data gathered during the nutrition assessment can be incorporated into the SOAP Note in the following manner:

S- Subjective Data:

-

statement of the individual's thoughts and feelings

-

individual complaints, "quotable" significant information, individual's

description of his or her problem, individual's statement of needs

-

information gained from talking with the individual, from others working

with the individual, or from the individual's relatives

-

dietary intake and reported food habits

O- Objective Data:

-

facts, tangible findings, clinical observations, documented information

-

physical findings, signs, symptoms

-

anthropometric data

-

laboratory data

-

factual information regarding background, history

-

environment, progress or problems

A- Assessment:

-

your assessment or impression of the individual's nutritional status,

needs, problems; assessment of the overall situation

-

summary and evaluation of dietary intake

-

meaning, value of the information presented

-

information still needed

-

problem definition, interpretation

P- Plan:

-

what the participant chooses as a goal in order to address their individual

nutritional status, need, or situation

-

what you plan to do to obtain more information and/or educate and treat

the individual

-

referrals

-

recommendations and plans for follow-up visits

-

educational materials used and given to the individual

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Attachment NE-5

MATERIAL EVALUATION FORM

Material Name/Title:

Type:

Obtained from:

Date Received:

By:

EVALUATION CRITERIA SPONSOR BIAS OR PROMOTION
Product name not visible

MINIMALLY ACCEPTABLE

ADEQUATE

CONTENT
Complete non-discrimination clause present (refer to RO Section for wording)

Accurate and up-to-date

Outcome x no more than 3 objectives x does not promote undesirable
behavior

Scope x topics deemed necessary x useful and relevant to target audience

Appropriate for target audience's lives and environment

Clear purpose of material

Organization x main ideas are clear x smooth flow of material

Learning experiences x seeks learner involvement x appropriate knowledge/skill level x suggests further learning

Summarization of ideas

References are accurate, up-to-date and usable

SUPERIOR

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Attachment NE-5 (cont'd)

EVALUATION CRITERIA

MINIMALLY ACCEPTABLE

LANGUAGE USAGE

Reading level appropriate for audience present (use SMOG)

ADEQUATE

Few technical terms used with definitions provided

Style x personal x few instances of negative wording x respectful, non-condescending tone x sentences simple, short, specific

x Use of words is consistent

STEREOTYPING Appropriate role models

Minority representation x presented in a factual manner x variety in roles, occupation, values

Lifestyle/cultural differences are reflected

SUPERIOR

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Attachment NE-5 (cont'd)

EVALUATION CRITERIA

MINIMALLY ACCEPTABLE

FORMAT

Paper quality is acceptable for intended use

ADEQUATE

Print x style acceptable x size appropriate

Topic headings/typographic cueing

Line width and spacing

Placement and use of illustrations

Placement and use of charts, table, graphs

Color x good choice x good quality

Pages x appropriate length x face to face

Overall visual appearance is pleasing

Quality of sound track is good

SUPERIOR

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Attachment NE-5 (cont'd)

Other Areas to be considered Prior to Purchase/Development:

EVALUATION CRITERIA
COST Original x material cost x shipping/handling x discount for multiples x easy to obtain x time to obtain

MINIMALLY ACCEPTABLE

ADEQUATE

Replacement x reasonable work life (durability) x predisposed to obsolescence x ease of repair (include
shipping/handling) x cost of replacement

Duplication x allowable/legal x cost of duplication

SUPERIOR

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Attachment NE-5 (cont'd)

EVALUATION CRITERIA
VIEWING/USAGE Space x available for viewing/use of materials x available for storage

MINIMALLY ACCEPTABLE

ADEQUATE

Easy to Use x staff x audience/client

Geared for x group classes x individual counseling/use x waiting room use

Is there an easier, more efficient way to stimulate the same behavior?

RECOMMENDATIONS:

SUPERIOR

SIGNATURE/TITLE OF EVALUATOR:

DATE:

Adapted from: E.M.P.O.W.E.R. (Evaluate Materials to Promote Optimal Use of WIC Education Resources), Massachusetts WIC Program, Department of Public Health, April 1985.

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GA WIC 2010 PROCEDURES MANUAL

WIC LOCAL AGENCY CONTINUING EDUCATION DOCUMENTATION LOG

District _________________________ CPA Staff: Minimum Requirement 12 Hours Yearly Year Reviewed: __________________

Name EX: Jane Doe

Title Nutritionist

Clinic 625

Training Type Clinical Skills

Training Date 8/25/2007

Training Hours
10 hours documented

Attachment NE-6

Start Date 1/1/2008

Total Hours

10 hours

Comments: _____________________________________________________________________________

Nutrition Assistants: Minimum Yearly Requirement 12 Hours Yearly Year Reviewed: __________________

Name EX: Nancy Drew

Title
Nutrition Assistant

Clinic 625

Start Date 1/1/2008

Training Type
Stress Free Feeding

Training Date

Training Hours

*Quarterly Clinic Observations Documented

1/1/2008

5 hours documented

Total Hours

5 hours

1/1/2008 by TES 4/17/2008 by TRS 7/7/2008 by TES 10/21/2008 by TRS

Comments: _____________________________________________________________________________

Note: Total CPA's/Nutrition Assistant's with adequate documentation divided by Total CPA's evaluated = % of CPA's with adequate documentation.
* Documentation of Nutrition Assistant Clinic Observations must include the dates and signatures of the Nutrition Coordinator or designees conducting the observations.
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GA WIC 2010 PROCEDURES MANUAL

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TABLE OF CONTENTS

Page

I.

Introduction ..............................................................................................................SP-1

A. Definitions...........................................................................................................SP-1

B. Certification ........................................................................................................SP-1

C. Food Delivery .....................................................................................................SP-2

D. Outreach and Referral .......................................................................................SP-2

E. Reporting and Monitoring................................................................................SP-3

II.

Individuals Residing in Non-Traditional Housing or

Institutions ................................................................................................................SP-3

A. Definitions...........................................................................................................SP-3

B. Services for Applicants or Participants Residing in Temporary Housing ..........................................................................................SP-4

C. Meals in Institutions and Temporary Housing .............................................SP-6

III. Other Special Populations ......................................................................................SP-7

A. Definitions...........................................................................................................SP-7

B. Limited English Proficient (LEP) Population.................................................SP-8

C. Refugees ..............................................................................................................SP-9

D. Native Americans ............................................................................................SP-10

E. Persons with Disabilities.................................................................................SP-10

IV. Referral and Outreach to Special Populations...................................................SP-10

GA WIC 2010 PROCEDURES MANUAL

Special Population

Attachments:

SP-1 Georgia Farm Worker Health Program ..............................................................SP-12 SP-2 Migrant Education Staff/Four Regional Offices ...............................................SP-13 SP-3 Telamon Corporation (Migrant and Seasonal Farm Worker
Association, Inc.) ....................................................................................................SP-14 SP-4 Interpreter Services ...............................................................................................SP-16 SP-5 Assurance Statement .............................................................................................SP-17 SP-6 Notice of Free Interpretation Services.................................................................SP-20 SP-7 Directory of Spanish Translators and Interpreters............................................SP-21 SP-8 Foreign Language Services for Africa, Asia, and Europe ...............................SP-24 SP-9 Waiver of Rights to Free Interpreter Services ...................................................SP-25

GA WIC 2010 PROCEDURES MANUAL

Special Population

I. INTRODUCTION
This section of the manual outlines program procedures for assuring access to WIC services and minimizing hardship for the segment of the population that requires non-traditional services. The program regulations require that all eligible and potentially eligible individuals have equal access to WIC benefits and services. Therefore, the local agency must make every effort to identify and reduce barriers that prohibit enrollment and service to eligible and potentially eligible clients.
WIC defines a special population as a group of persons with common needs that require special assistance and/or specific services to access and participate in WIC related services. Special population groups referenced in this section are: migrants, loggers, applicants/participants residing in institutions, homeless people, Limited English Proficient People, Native Americans and persons with disabilities. Local Georgia WIC Programs are responsible for ensuring accessability to WIC services for these populations.
A. Definitions
1. Migrant Farm Workers are individuals (and family members) employed seasonally in agriculture occupations, who establish temporary residence for the purpose of such employment, and have been employed in such occupation within the last twentyfour (24) months.
2. Loggers are individuals whose principal employment is seasonal harvesting of trees, who have been employed in this activity within the last twenty-four (24) months and for such employment established a temporary abode.
3. Seasonal Farm Workers are individuals employed in agriculture occupations who do not move from place to place establishing temporary residence for the purpose of work. THEY ARE NOT migrant farm workers as defined by the Georgia WIC Program.
B. Certification
The process for certifying migrant farm workers must comply with standard program procedures (See Certification Section). The local agency must issue an Electronic Verification of Certification (EVOC)/Verification of Certification (VOC) card to every migrant at the
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GA WIC 2010 PROCEDURES MANUAL

Special Population

time of certification. A valid EVOC/VOC card helps migrant farm workers access WIC services (See Certification Section - Transfer of Certification). The VOC card is valid until the certification period expires.
WIC certification must be documented with an EVOC/VOC card or a copy of the Georgia WIC assessment form. In lieu of a VOC card, a Georgia WIC Identification (ID) card is acceptable. However, the receiving clinic must verify the information on the Georgia WIC ID Card. Vouchers must only be issued for thirty (30) days if clinic staff cannot verify certification information with the originating clinic.
C. Food Delivery
Migrants frequently remain in a local area for a very short period. It is essential that migrant certification, transfer of eligibility, and receipt of WIC foods are received as expeditiously as possible. Vouchers must be issued on the same day the migrant participant is certified.
When a migrant presents WIC vouchers from another state, the certifying clinic should void the vouchers and issue Georgia WIC vouchers as replacements. The certifying clinic must send the voided vouchers back to the state in which the vouchers originated. The local agency must forward the voided vouchers to the appropriate state agency. If a migrant presents vouchers from another clinic in Georgia, the clinic staff should instruct the migrant to redeem them if they have a valid issue date (See Food Delivery Section).
D. Outreach and Referral
In geographical areas where there is significant movement of migrants' dwellings, the local agencies are required to make special effort to reach out and serve this population. The local agency should decide whether evening clinics or certifications at migrant camps are necessary. This decision should be based on migrant outreach efforts and consultation with organizations serving migrants as well as other migrant activities in the service area. All services necessary to serve migrant populations should be implemented. Special outreach and referral efforts implemented by a local agency to provide access to health services for the migrants and their families should be documented.

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Special Population

E. Reporting and Monitoring
The number of migrants participating in the Georgia WIC Program is reported on the Racial/Ethnic Participation Report generated by the Automated Data Processing (ADP) Contractor each month. Migrant information on the Turnaround Document (TAD) is completed with a Yes (Y) or No (N). To accurately determine the migrant status of an applicant or a participant, the following question must be asked, "Are you a migrant"? If necessary, WIC's definition of a migrant should be explained to the applicant/participant.
Migrant activity and expenditures are also reported on the Quarterly Status Report. The state agency is responsible for monitoring migrant services provided by local agencies. Migrant activities will be monitored according to the procedures outlined in the Monitoring Section of the Georgia WIC Procedure Manual. Local agencies with significant migrant populations, as outlined in the Monitoring Section, must conduct migrant specific outreach.

II. INDIVIDUALS RESIDING IN NON-TRADITIONAL HOUSING OR INSTITUTIONS
Local agencies must continue to serve and enroll eligible participants and applicants living in non-traditional housing environments. The Georgia WIC Program defines non-traditional housing as living accommodations where individuals or families reside for a particular purpose or need. These accommodations include, but are not limited to, private and public institutions, homeless shelters, temporary housing, (including the residences of another person), and special drug rehabilitation homes for pregnant women. Both applicant/participant and non-traditional housing representatives must comply with program procedures and policies as outlined in Section SP-II, C.
Non-traditional housing representatives who provide accommodations for WIC participants must sign an Assurance Statement (Attachment SP-5). The signed copy of this agreement, in accordance with USDA Federal Register, Volume 54, No. 239, must be on file with the Georgia WIC Program before clients may be served.
A. Definitions
Services and program benefits must be tailored to meet the special needs of individuals defined in these groups.

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GA WIC 2010 PROCEDURES MANUAL

Special Population

Institution is any residential accommodation, which provides meals and sleeping accommodations to a special group of people, or a facility designated as a residence for individuals intended to be in a controlled environment. Excluded are private residences and homeless facilities.
Homeless facility is a public or private supervised facility, which provides temporary living accommodations and meal services for individuals who lack a fixed and regular nighttime residence.
Homeless Individual means a woman, infant or child: a. Who lacks a fixed and regular nighttime residence. b. Whose primary nighttime residence is: 1. A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodations. 2. An institution that provides a temporary residence for individuals intended to be institutionalized. 3. A temporary accommodation of not more than 365 days in the residence of another individual. 4. A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
Temporary Housing refers to a residential facility or home for individuals who have lost their primary place of residence and relocate to a short term lodging facility in a private or public residence. Individuals in this category include, but are not limited to: battered women and their children in temporary shelters; homeless persons; pregnant teenagers in group homes; and individuals whose primary residence is lost as the result of a disaster.
B. Services for Applicants or Participants Residing in Temporary Housing
Local Georgia WIC Programs are responsible for ensuring accessibility to WIC services for individuals who have lost their usual (or primary) place of residence or who may be residing in temporary housing. Individuals who reside in temporary housing represent a high-risk population due to their compromised health and nutrition status and high levels of anxiety and stress. Sensitivity should be displayed with these individuals when gathering application and certification information. WIC procedures should be explained thoroughly. Applicants and participants must be

SP-4

GA WIC 2010 PROCEDURES MANUAL

Special Population

provided services in accordance with the regulations and requirements of the Georgia WIC Program (See Certification Section for Program Policies).
Individuals in this category include, but are not limited to: battered women and their children, homeless persons who may be residing in vehicles, parks, hallways, doorsteps, sidewalks, abandoned buildings, temporary shelters, hotels, motels, etc.; pregnant women residing in drug rehabilitation facilities and pregnant teenagers in a group home. Also included are individuals whose primary residence is lost as the results of a disaster (See Disaster Section).
Local agencies should make every effort to certify these applicants immediately, i.e., during the initial clinic visit. Local agencies should be flexible when issuing vouchers. If a participant is no longer residing in the clinic service area where they last received vouchers, the vouchers should be issued and the participant transferred to the nearest clinic. Employees of institutions may not serve as proxies for the residents.
Due to the nature of their temporary residence, cooking facilities, refrigeration, and acceptable storage areas may not be available. Therefore, special consideration must be given to the issuance of supplemental food packages in order to meet the participant's nutritional needs. The types of supplemental foods prescribed must take into account the cooking and storage facilities available to the participant. The food package should be tailored using alternative food packages or manual vouchers to:
1. Offer smaller amounts of more perishable foods and larger amounts of less perishable foods (amounts not to exceed Federal Regulations).
2. Offer canned evaporated milk and/or dry powder milk.
3. Offer ready-to-feed and/or powdered formula when sanitation or storage is a problem.
Education related to the use and storage of food is very important for WIC participants who reside in temporary residences. The educational information should include the following:
1. Discuss spreading out redemption of vouchers over the 4-week period.

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GA WIC 2010 PROCEDURES MANUAL

Special Population

2. Offer information on food storage and sanitation, when applicable.

C. Meals in Institutions and Temporary Housing
The Georgia WIC Program applicants/participants who reside in institutions or temporary housing, which serve meals, may participate in the Georgia WIC Program. This may be a permanent or temporary residence such as a homeless shelter, group home, shelter for battered women, rehabilitation facility, etc.
When determining eligibility for participation in the Georgia WIC Program, the institution and participant must adhere to the following requirements.
1. When determining income eligibility and family size of the individual(s) residing in temporary housing accommodations, do not include other residents of the institution or the temporary housing facility. The applicant's income is also separate from the general revenues of the institution.
2. The residential facility must not accrue financial or in-kind benefit from a person(s) participation in WIC. For example, transferring WIC foods to the general inventories of the facility or reducing the quantity of food provided to WIC participants.
3. Food items purchased with WIC vouchers must not be used in communal feedings. WIC foods are supplemental foods intended to enhance the participant's diet and nutritional needs. If these foods are used in the communal food supply, the intent of the supplemental foods is not fulfilled.
4. No institutional constraints may be placed on the WIC participant's ability to partake of the supplemental foods and WIC associated services and benefits. Participants must have full, free, and direct access to all program benefits and services available.
The above conditions have been established to ensure that: a. Participants, rather than the institution, benefit from the
Georgia WIC program. b. All eligible persons participate in WIC in the same

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GA WIC 2010 PROCEDURES MANUAL

Special Population

manner and to the same degree as persons without institutional affiliation. It is vital that adequate documentation regarding these applicants/ participants is included in the medical record. This documentation includes, but is not limited to: 1. The institution where the applicant/participant resides.
2. The above conditions addressed in Section II C. 2, 3, and 4 were discussed and are understood by the applicant/participant.
3. Each applicant/participant has been informed of their rights and obligations, both verbally and in writing.

III. OTHER SPECIAL POPULATIONS
The local agencies must make every effort to alleviate barriers to WIC services for all eligible and potentially eligible individuals during critical times of growth and development. Other special population groups that the Georgia WIC Program seeks to serve include, but are not limited to individuals who may experience barriers to program services due to physical conditions, language, vision and hearing impairment, and cultural differences.
A. Definitions
The following definitions define groups identified in this section as other special population groups.
Hearing impaired refers to a person who cannot hear or has limited ability to hear.
Multilingual means the person speaks two or more languages fluently.
Native American is used to designate an American Indian or original inhabitants of America.
Non-English speaking refers to an individual whose primary language is not English or an individual who speaks little or no English.
Vision Impaired refers to an individual with limited ability or the inability to see.
Refugee refers to someone who flees his or her country to another country

SP-7

GA WIC 2010 PROCEDURES MANUAL

Special Population

to seek protection or relief from persecution because of race, religion, nationality, their political opinion, or membership in a social group.
B. Limited English Proficient (LEP) Population
Individuals whose primary language is not English, and who do not read or speak English well enough to have access to WIC services and benefits provided in local clinics may be considered members of the Limited English Proficient population. The local agencies are responsible for ensuring that multilingual staff, volunteers, or other translation resources are available to serve Limited English Proficient (LEP) participants or LEP applicants (See Attachments 4, 7 and 8).
In areas where a substantial number of persons have Limited English Proficiency, local agencies must carry out outreach activities to insure that eligible members of such populations participate in the program. Contact should be made with other agencies and community organizations serving LEP persons. A variety of nutrition education and breastfeeding materials are available in Spanish through the Office of Nutrition.
If there is a need for materials in other languages, the local agency should contact the Georgia WIC Program or the Office of Nutrition for assistance. The Refugee Health Program has developed and compiled a library of translated health education materials. These materials are distributed, upon request, to organizations and individuals (See Attachment SP-4).
Local agencies may contract with translators or interpreters as needed. However, local agencies are encouraged to first hire multilingual staff in their programs to provide these services. Limited language interpretation services are available through the State Refugee Health Program. Specific areas of the state have also identified available interpreters (See Attachment SP-4). The Office of Nutrition will assist local agencies in identifying multilingual translators or interpreters.
WIC applicants or participants shall not be denied WIC services or benefits because they did not bring an interpreter to their appointment. It is the responsibility of the Georgia WIC Program to provide interpreters for WIC Services. Free interpreter services are available through agencies of the Georgia Department of Community Health. Although free interpreter services are available, an applicant or a participant may choose his or her interpreter, such as a family member or friend who may not be a qualified or certified interpreter. In instances when an interpreter attends a WIC visit as the client's interpreter, the applicant or participant must

SP-8

GA WIC 2010 PROCEDURES MANUAL

Special Population

sign the "Client Waiver of Rights to Free Interpreter Services" form. (Attachment SP-9)
The Local agency staff must inform an applicant or a participant of the availability of qualified certified interpreter at no cost. After the information is communicated and the applicant or participant makes an informed choice to use the interpreter of his or her choice, the signed "Client Waiver of Rights to Free interpreter Services" documents that choice.
The client's interpreter will sign an acknowledgement of his or her responsibility and provide an oral translation of the informed choices statement to the WIC applicant or participant. Documentation of the actions along with a copy of the signed document must be retained in the applicant or participants record.
Federal Regulations, Section 7CFR, 246.14 (c) (5) states that the cost of translators for materials and interpreters are allowable costs. Therefore, these services are allowable and WIC funds may be used to secure these services.
The local agency must post the Notice of Interpretation Services Sign in the waiting room, front office, or voucher issuance area for WIC applicants. The purpose of this sign is to indicate to the applicant that services are available at no charge to them in other languages upon request. The displaying of this sign will be monitored on program and self reviews (See Attachment SP-6).
C. Refugees
A refugee is someone who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group. With the significant number of refugees coming to the state, every effort will be made to ensure that services are extended to this population (See Attachment SP4). Aliens (legal and illegal) are eligible to apply for WIC on the same basis as United States citizens.
The Division of Public Health, Refugee Health Program staff includes interpreters who speak Amharic, Bosnian, Cambodian, Russian, Somali, Tigrinya, and Vietnamese. Program interpreters help refugees access health care by making appointments, arranging transportation, and providing interpretation at appointments.

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GA WIC 2010 PROCEDURES MANUAL

Special Population

D. Native Americans
The Georgia WIC Program should make every effort to locate and enroll all eligible Native Americans residing within a local agency service area.
E. Persons with Disabilities
The Georgia WIC Program is required to make program services accessible to individuals covered by the Americans with Disabilities Act. Local agencies are responsible for ensuring that individuals with disabilities are accommodated in the Georgia WIC Program. All facilities where WIC and related services are provided must be physically accessible from the outside as well as on the inside. The local programs are required to provide capabilities for communicating with vision and hearing impaired participants and applicants. Interpreters for the hearing impaired, are available through the State Rehabilitation Program (See Attachment SP-4)
IV. REFERRAL AND OUTREACH TO SPECIAL POPULATIONS
Local agencies must develop a network for coordinating activities with local organizations and person serving and providing resources to special population groups and minority populations. Local agencies should advise the Georgia WIC Program of organizations and resources available in their local service area in order to maintain a current listing of statewide resources and services for migrants and special populations. Using updated information provided by the local agencies, the state agency will compile a statewide listing for persons and organizations serving migrants and other minorities (See Attachments SP-1, SP-2, SP-3 and SP-4). Local agencies should contact and distribute outreach materials to other agencies offering services to persons who reside in temporary locations. Health care may not be accessible to individuals who reside in temporary locations. Therefore, these individuals should be referred to any and all health services provided by local agencies. These high-risk individuals must be referred to appropriate local health and human service agencies such as: 1. Temporary Assistance for Needy Families (TANF) and client assistance
services. 2. Food pantries and meal programs 3. Local shelters 4. Food Stamps 5. Legal services
SP-10

GA WIC 2010 PROCEDURES MANUAL

Special Population

Other pertinent outreach and referral procedures may be found in the Outreach Section of the Procedures Manual.

SP-11

GA WIC 2010 PROCEDURES MANUAL

Attachment SP-1

Georgia Farm Worker Health Program Cordele, GA 31010-0310
Phone: (229) 401-3086 3096 Fax: (229) 401-3077

Isiah C. Lineberry, Executive Director, Office of Rural Health Services, Email: ilineberry@dch.state.ga.us Tony Brown, Migrant Health Coordinator, Office of Rural Health Services, Email: tbrown@dch.state.ga.us
Ted Meisner, Field Data Consultant, 478-746-9659, Email: laermita@asburyusa.net FAX: 630-929-1364

Project Sites Ellaville
Coffee Ellenton
Valdosta

Migrant Program Staff

Telephone/Fax

Mary Anne Shepherd, FNP, P/Coordinator Shelby Clark, RN. Angelica Carranza, ORW Angie McIllrath, ORW Rosa Cazares, ORW Shirley Jones, Office Manager Michelle Doggett, Accounting

Tel: (229) 937-5321 Fax: (229) 937-2232

Address
Ellaville Primary Medicine Clinic 103 Broad Street P.O. Box 65 Ellaville, GA 31806-9428
E-Mail: mshepherd@sumterregional.org

Counties Served
6/27/01
Schley Sumter Macon Taylor Crisp

Josie Haklin, RN, P/Coordinator Kaye Hulett, Accounting Clerk Sherrill Carver, Cost Report Angelica Gomez, ORW

Tel: (912) 389-4450 Fax: (912) 389-4326

Coffee County Health Department 1111 West Baker Highway Douglas, GA 31533-4920

Blainette Hanson, FNP Dana Reddick, Nurse Manager Marisela Resendiz, Nurse's Aid Kathy French, Data Entry Jose Palomares, ORW Celines Quinones, ORW

Tel: (229) 324-2845 Fax: (229) 324-3383

Ellenton Clinic 103 Baker Street P.O. Box 312 Ellenton, GA 31747

Jody Horne, Cost Reports

Tel: (229) 891-7100

Colquitt Health Department Moultrie, GA

Barbara Jackson, District Contact Mary Ann Bland, Accounting
Steve Graham, President/CEO Dr. Manual Tovar, MD Janie McGhin, ANP-C Lydia Naylor, RN Julissa (Julie) Clapp, ORW Tomi McCain, Receptionist, ORW Dr. Antonio Gracia, MD

Tel: (229) 430-4575 Fax: (229) 912-4305143
Tel and Fax: (229) 559-9910 Steve Graham's Fax: (229) 242-0490

1109 N. Jackson Street Albany, GA 31701-2022
Airport Medical Clinic Culpepper Road P.O. Box 889 Lake Park, GA 31636

Atkinson Coffee
Colquitt Tift Cook Brooks
Echols Lowndes

SP-12

GA WIC 2010 PROCEDURES MANUAL

Attachment SP-2

MIGRANT EDUCATION STAFF Mary Jo Crawford, Director
Georgia Migrant Education Program Georgia Department of Education 1854 Twin Towers East Atlanta, GA 30334 (404) 656-2030
REGIONAL OFFICES
Chattahoochee Flint Regional Education Service Agency P.O. Box 588
Americus, GA 31709 (229) 937-5341
Migrant Education Association Live Oak
P.O. Box 780 Brooklet, GA 30415
(912) 424-5400
Piedmont Migrant Education Association 3536 East Hall Road Gainesville, GA 30507 (770) 536-5717
Southern Pine Migrant Education Association P.O. Drawer 745
Nashville, GA 31639 (229) 686-2053

SP-13

GA WIC 2010 PROCEDURES MANUAL

Attachment SP-3

TELAMON CORPORATION (Migrant and Seasonal Farmworker Association, Inc.)

Herbert Williams, State Director 2720 Sheraton Dr., Suite 140D Macon, GA 31204-1167 (478) 873-6575

Field Offices

Offices Valdosta Office 200 East Mary Street Valdosta, GA 31601 (229) 244-4920

Supervisors Carmen Wilkinson Program Coordinator

Lyons Office 120 East Liberty Avenue Lyons, GA 30436 (912) 526-3094 (912) 526-5906 (FAX)

Elmira Reynolds Employment and Training Specialist

Dublin Office 112 East Johnson Street Dublin, GA 31021 (478) 275-0127 (478) 275-7548 (FAX)

Barbara Mosley Employment and Training Specialist

Douglas Office 613 West Baker Hwy P.O. Box 966 Douglas, GA 31533 (478) 384-8856 (478) 384-8929 (FAX)

Myrtice Moore Employment and Training Specialist

Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, GA 30358 (912) 764-6169 (912) 489-6516 (FAX)

Elsie Trethaway Employment and Training Specialist

SP-14

GA WIC 2010 PROCEDURES MANUAL

Attachment SP-3 (cont'd)

Offices Moultrie Office 19 First Street S.E. Moultrie, GA 31776 (229) 985-7507 (229) 985-7305 (FAX)

Supervisors Beverly Scretchen Employment and Training Specialist

Blackshear Office 3351 West Highway 84 P.O. Box 413 Blackshear, GA 31516 (912) 449-3016 (912) 449-4579 (FAX)

Sharon Moody Deputy Director

MIGRANT HEAD START PROGRAMS

1)

Ms. Sandra Adams, Director

KIDDIE KASTLE I

684 N. Washington Street

Lyons, GA 30445

(912) 526-9556

(912) 526-3434 (FAX)

2)

Ms. Betty Mincey, Director

KIDDIE KASTLE II

111 Oliver Lane

Glennville, GA 30427

(912) 654-2182

(912) 654-2190 (FAX)

3)

Ms. Gloria Sandoval, Director

KIDDIE KASTLE III

133 Serena Drive

Norman Park, GA 31771

(229) 769-3627

(229) 761-3182 (FAX)

SP-15

GA WIC 2010 PROCEDURES MANUAL

Attachment SP-4

INTERPRETER SERVICES
STATE REFUGEE HEALTH PROGRAM INTERPRETERS
Monica Vagas , Acting State Refugee Health Coordinator (404) 679-4999
Below are lists of interpreters available in specific areas of the State. For interpreter services not listed below, or for general information regarding health services for refugees, call the State Refugee Health Program at (404) 657-2550.

Greater Atlanta

REFUGEE HEALTH INTERPRETERS

Sabina Brovic Chanthary Chea Bay Ngyun Zyan Amedi Siya Kim Margarita Tselesin Halema Hasashi

Bosnian Cambodian, Vietnamese Vietnamese Kurdish Cambodian Russian Somalia

(404) 294-3816 (404) 508-7785 (404) 657-2552 (404) 294-3816 (404) 657-2563 (404) 657-2641 (404) 657-6716

Gainesville

Anita Gougelmann Vietnamese

(770) 531-5600 GIST 261-5600

DFCS STATE REFUGEE COORDINATOR

Barbara Burham

(404) 657-3428

Two Peachtree ST NW

19th Floor

Atlanta, GA 30303

GEORGIA INTERPRETER SERVICES FOR THE HEARING IMPAIRED

David Cowan, Director 44 Broad Street, NW Suite 503 Atlanta, GA 30303

(404) 521-9100 Fax: (404) 521-9121

LIST OF INTERPRETER SERVICES

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-4 (cont'd)

SIGN LANGUAGE
The Interpreting Resources of Georgia, Inc. Qualified Sign Language Interpreting Services 4651 Woodstock Road Suite 203-125 Roswell, Georgia 30075 Contact: Don Clark (770) 928-6735 (Voice/TTY) (770) 928-6596 E-mail: Declark@aol.com
Interpreter service (148 Different Languages) Language Line Services Open 24 hours a day Contact: Julia Metzger to set up contact Toll Free Number: (877-862-1302 E-mail: www.LanguageLine.com
Medical Interpreters Medical Interpreters Network of Georgia (Spanish Only) Contact Susan Martorell (404) 378-5067

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-5

ASSURANCE STATEMENT In accordance with the Federal Register, Vol. 54, No. 239, regarding the homeless and provision of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC),
(Name of shelter/facility)
...assures the Georgia WIC Program that it will adhere to the following conditions:
1. The facility will not accrue financial or in-kind benefits from resident's participating in WIC. For example, the facility may not transfer WIC foods to its own general inventories or reduce the quantity of food that would have otherwise been provided to the WIC participant.
2. Food items purchased by the Georgia WIC Program will not be used in communal feedings. WIC provides specific supplemental food intended to meet the individual needs of participants in crucial stages of growth and development. If WIC foods were used in communal feedings, they would not enhance the WIC participant's diet to the degree intended.
3. The facility places no constraints on the ability of the WIC participant to partake of supplemental foods and all associated WIC services made available to participants by the local WIC agency. The participant must be given free, full, and direct access to all Georgia WIC program benefits such as is available to participants not associated with an institution.
The Georgia WIC Program or the local WIC agency may at it discretion, make site visits to monitor compliance to the above conditions and/or investigate complaints.
The "Assurance Statement" will remain on file in the Georgia WIC Program until such time as the shelter/facility notifies the Georgia WIC Program that it no longer wishes to participate according to the ascribed conditions and/or it is determined by the Georgia WIC Program that the agency is not in compliance.
The undersigned agrees to the conditions stated and declares that he/she is the duly authorized representative of the named shelter/facility, and as such, is authorized to enter into the agreement:

(Name of shelter/facility)

(Street address or P.O. Box)

(City, State, Zip County)

(Area code-telephone number)

(Hours of telephone coverage am to pm)

Signature (Authorized Representative)

Date

Title

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-5 (cont'd)

Please return completed and signed statement to:
Georgia WIC Program Division of Public Health Georgia Department of Community Health Two Peachtree Street, NW
10th Floor, Suite 10-476 Atlanta GA 30303

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-6

SP-20

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Attachment SP-7

Directory of Spanish Translators and Interpreters
Atlanta Association of Translators and Interpreters (AATI) P.O. Box 12172, Atlanta, GA 30355
AATI, a non-profit, professional association serving Atlanta and Georgia communities, is a communications linkage to people with limited English proficiency. These professionals specialize in Spanish, French, Portuguese and other languages for medicine, health, government, education, business and law. They are certified translators and interpreters for universities, colleges, U.S. federal government, U.S. Department of State, American Translators Association and Georgia State University. AATI members come from all corners of the world and possess extensive cultural sensitivity, along with a deep understanding of customs, mores, business, and etiquette.
AATI members specializing in Spanish
Translator Solution (Spanish translator and interpreter) 2830 Biscayne Drive, Conyers, GA 30012 Contact: Marilu Montalvo Tel: (770) 482-2517 Cell: (404) 323-1904 E-mail: m660-@quixnet.net

Susana Marci Brady (Spanish translators, interpreter, voice-over-talent) 1076 Greenbriar Circle, Decatur, GA 30033 Tel: (404) 296-1363 E-mail: susanamb@aol.com

Maloof Language Services, Inc. (Spanish/Portuguese/French to English) 7346 Cardigan Circle, Atlanta, GA 30328 Contact: Mary C. Maloof Tel: (770) 698- 9149 Fax: (770) 698-8112 E-mail: mmaloof@printmail.com

FC Translation Services (English to Spanish) 1656 Tichenor Court, Dunwoody, GA 30338 Contact: Floralba Chincilla Tel: (770) 395-1029 Fax: (770) 359-9936 E-mail: CO102@mindspring.com
Business Linguistics, Inc. (Spanish language and cultural classes) 14 West Peachtree Place, NW, Atlanta, GA 30308 Contact: Monica Redondo Tel: (404) 892-9666 Fax: (404) 588-1188 E-mail: BusLinguis@aol.com

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-7

Judy R. Palmer (Freelance translator, interpreter, editor, proofreader in Spanish) 879 Springdale Road, Atlanta, GA 30306 Contact: Judy R. Palmer (404) 373-9621 Fax: (404) 479-6260 E-mail: Jurepal@mindspring.com
Elena N. Treto (Freelance translator in Spanish) Post Office Box 13623, Atlanta, GA 30324 Tel: (404) 633-7290 Fax: (404) 248-9645 E-mail: entreto@mindspring.com
Claudia Mendez Porter (Spanish translator and interpreter) Tel: (770) 736-2994 Fax: (770) 609-5242 E-mail: cmp@avana.net
Cathy McCabe (Spanish interpreter and translator) E-mail: cathspan@mindspring.com
Joaquin J. Coello (Certified Mediator and Arbitrator) 479 Wall Street, Marietta, GA 30068 Tel: (770) 973-5094 Fax: (770) 973-5094? E-mail: jcoello@csi.com
Clara Marcela Lievano (Spanish translator and interpreter services for legal/medical) 246 Ennisbrook Drive, Smyrna, GA 30082 Tel: (770) 803-0093 Work #(404) 250-2877 E-mail: clievano@mindspring.com
Ligia Mejia (English-Spanish translator) Tel: (770) 345-1251 E-mail: Lsrey@bellsouth.net
Maria Luisa Saucedo (Spanish translator) Tel: (340) 713-1584 E-mail: marilu85@go.com
Daniel G. Saavedra (Spanish translator and interpreter) 2772 Hawk Trace Court, Marietta, GA 30066-1535 Tel: (770) 982-8216 Fax: (770) 924-4707 E-mail: dansaav@mindspring.com

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-7

LW Translation Service 7185 Amberleigh Way, Duluth, GA 30097 Tel: (770) 622-4176 E-mail: lourdeswyly@mediaone.net

Lingo Link (Professor of Spanish language and small business owner) Contact: Bunderlai Souto Duhham Tel: (770) 753-8882 Fax: (770) 442-6040 E-mail: Bunderlai@mindspring,com

Bilingual Crosscultural Communications (Spanish translation, voice talent, writer) 2519 Gravey Drive NE, Atlanta, GA 30345 Contact: Yvonne de Wright Tel: (770) 493-6518 Fax: (770) 934-6996 E-mail: ydwright@aol.com

Annie Lidback Castro (Spanish, Portuguese and Italian translation services) E-mail: TransAL@alo.com

Velasco Language Services (Spanish translation of immigrant documents, etc.) 5715 Sunset Maple Drive, Alpharetta, GA 30005 Contact: Pablo Velasco Tel: (770) 663-4042 E-mail: pvelasco@worldnet.att.net
Susie Maratorell (Spanish translations of medical, legal and government policies) 1006 Clifton Road, Atlanta, GA 30307 Tel: (404) 931-6619 E-mail: susy@mindspring.com

Workplace Spanish, Inc. (Full services Spanish translations and classes) Contact: Tom Sutula Tel: (770) 993-4075 Fax: (770) 992-0390 E-mail: tom@workplaceSpanish.com

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-8

Foreign Language Services for Africa, Asia, and Europe

Georgia Mutual Assistance Association Consortium (GMAAC) 4151 Memorial Drive, Suite 200-D, Decatur, GA 30032 Contact: Fatana Pirzad or Marge Flaherty Tel: (404) 296-5400 Fax: (404) 296-0036
GMAAC is a non-profit organization that provides social adjustment, case management, and other services to refugees and immigrants in the greater Atlanta area. GMAAC was organized in 1984 by refugees and has served the refugee and immigrant community for over 16 years. The staff at Georgia Mutual Assistance Association Consortium speak 11 different languages and provides interpretation and translation services for medical and legal issues in Somali, Serbo-Croatian, Amharic, Farsi, Vietnamese, Cambodian, Russian, Albanian, Arabic, Laotian, Korean, French, Gujarti, Hindi, German, Italian, and Spanish. Community interpreter services charges a fee of $35.00 per hour and requests 7 to 10 days prior notice before appointments are scheduled. GMAAC also operates youth programs for refugee children in Clarkston, Stone Mountain and South Atlanta.

Vietnamese English Interpreters P.O. Box 941694, Atlanta, GA 30041 Contact: Y n Tran Tel: (404) 277-4644 A volunteer group that helps the Vietnamese community with free medical and legal translation and interpreter services at no charge.

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GA WIC 2010 PROCEDURES MANUAL

Attachment SP-9

Georgia Department of Community Health
Waiver of Rights to Free Interpreter Services

Free interpreter services are available through agencies of the Georgia Department of Human Resources (DHR) will call an interpreter after identifying the primary language in which you are able to communicate. You are entitled to bring your own interpreter, however, DHR or its representative agencies will not authorize payment for interpreter services not previously secured or approved by DHR.

I, __________________________, have been informed of my right to receive free interpretive (Client Name)

services from ____________________________________. I understand that I am entitled to (Agency)

interpretive services at no cost to myself or to other family members, but do not wish to receive

DHR's free services at this time. I choose _________________________________to act as my (Interpreter's Name)

interpreter from ___________________________ until ______________________________ .

(Date)

(Date)

I understand that I may withdraw this waiver at any time and request the services of an

interpreter, which will be paid for by ________________________________________________ (DHR Agency)

To the best of my knowledge, the person I am using to act as my own interpreter is over the age of 18. I understand that this waiver pertains to interpreter services only and does not entitle my interpreter to act as my Authorized Representative. I also understand that the service agency may secure a qualified or certified interpreter to observe the interpreter of my choice during the interpreting session to ensure the accuracy of the communication and follow-up instructions.

The interpreter indicated below orally translated this form to me.

(Client's Signature)

(Date)

(Interpreter's Signature)

(Date)

(Interpreter Printed or Typed Name and Signature)

(Date)

(Staff Person Signature)

(Date)

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GA WIC 2010 PROCEDURES MANUAL

Outreach

TABLE OF CONTENTS Page
I. General ....................................................................................................................... OR-1 II. Methods of Outreach ............................................................................................... OR-1 III. Agencies to Contact for Outreach........................................................................... OR-2 IV. Public Notification .................................................................................................... OR-3 V. Public Comments Period ......................................................................................... OR-3 VI. Outreach during a Waiting List ............................................................................. OR-3
A. Outreach ........................................................................................................ OR-3 B. Coordination with Government Entitlement Program .......................... OR-3
VII. Program Costs ........................................................................................................... OR-4 VIII. Coordination/Integration of Services.................................................................... OR-4
A. Outreach ......................................................................................................... OR-4 B. WIC/Medicaid Coordination...................................................................... OR-4 C. WIC Coordination Strategies ...................................................................... OR-4 D. WIC Works Resources Center ..................................................................... OR-5 E. Georgia WIC Program Facts Information Sheet....................................... OR-5

Attachments: OR-1 BPHC: Service Delivery Sites ................................................................................. OR-9 OR-2 Georgia Association for Primary Health Care, Inc ............................................ OR-21 OR-3 Georgia Farm Worker Health Program Sites...................................................... OR-28 OR-4 District Map ............................................................................................................. OR-29

GA WIC 2010 PROCEDURES MANUAL

Outreach

I. GENERAL
Outreach activities are those promotional efforts designed to encourage and/or increase participation in the WIC Program. The purpose of outreach is to:
1. Increase public awareness of the benefits of the WIC Program 2. Inform potentially eligible persons about the WIC Program in order to
encourage and promote their participation in the program. 3. Inform health and social service agencies of the WIC Program's eligibility
criteria for participation and to encourage referrals. 4. Ensure cooperation and coordination between WIC benefits and other
related services and programs for participants. 5. Promote a positive image of the WIC Program. 6. Generate additional outreach material in other languages as appropriate.
Each local agency must conduct outreach and referral activities to coordinate the WIC Program with other programs and services, which serve potential WIC applicants. The outreach activities conducted must be documented and kept on file for four (4) years.
When funds are available, the Georgia WIC Program will develop and provide general outreach materials for use by local programs.

II. METHODS OF OUTREACH
Outreach activities should be aimed directly at potentially eligible persons through the use of informational posters, brochures, displays in public places, presentations at meetings and clubs, advertisements through local newspapers, radio, or television. If a local agency serves a significant number of persons whose primary language is not English, the local agency must make outreach materials available to this population in their language. Additionally, the state and local agencies must contact grass root organizations such as the Latin American Association, the National Association for the Advancement of Colored People (NAACP), or churches.
The WIC HOTLINE continues to be available for information on WIC services. The WIC HOTLINE was established to give vendors, clients, staff and the general public direct access to the State WIC Program at no cost. This toll-free number, 1-800-228-9173, is available on printed materials and is provided during radio and television interviews.

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GA WIC 2010 PROCEDURES MANUAL

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The eighteen (18) Districts and two contracted WIC agencies are encouraged to communicate regularly with agencies providing services to families. These agencies are inclusive of governmental, quasi-governmental, private not-forprofit organizations, and citizen participation groups.

III. AGENCIES TO CONTACT FOR OUTREACH
State and local agencies shall provide WIC Program applicants and participants or their designated proxies within information on other health related and public assistance programs, and when appropriate, shall refer applicants and participants to such programs. (CFR Part 246.7 Subpart C.b)
Examples of agencies, offices, and organizations that should be contacted regarding outreach, referral, and coordination of services include:
1. Alcohol/Drug Abuse Counseling and Treatment Centers 2. Family Planning Programs 3. Child Abuse Counseling Centers 4. Physicians, Obstetricians, Pediatricians, Family Practitioners, Nurses and
Nurse Practitioners 5. Health and Medical Organizations, Hospitals, Community Centers and
Clinics 6. Pharmacies 7. Public Assistance Offices 8. Unemployment Offices 9. Social Service Agencies 10. Religious and Community Organizations 11. Agencies offering services for Homeless Families and Individuals 12. Housing Authorities 13. School-Based Health Clinics 14. Migrant Health Centers, Migrant Offices, Logging, and Agricultural
Communities 15. Military Bases 16. Retail Stores 17. Day Care Centers 18. Charitable Organizations (Goodwill, Salvation Army, etc.) 19. Head Start Programs

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IV. PUBLIC NOTIFICATION
The State Agency, through the Office of Public Information, will distribute outreach information to every newspaper and radio station in Georgia, at least annually. All outreach materials must include the USDA non-discrimination statement.

V. PUBLIC COMMENTS PERIOD
The Georgia WIC Program has developed a website (on the Public Health Website) where all WIC advocates, participants, vendors and the general public have an opportunity to make comments on the operations of the WIC program. This site will be open all year for general comments. Additionally, to ensure that everyone has access to the website address, all information, pamphlets, letters, etc. given to health department staff, WIC advocates, applicants, participants, vendors and the general public will have the website address for their comments at any time.
During the Comment Period, which is now open all years, WIC Program regulations and guidelines will be made available to the public upon request. This includes Federal Regulations, the State Plan, the Procedures Manual and the Income Guidelines.
Once a year, the Department of Public Affairs prepares new releases to notify the general public of WIC benefits and notices soliciting public comments on WIC operations. The news releases are sent to newspapers statewide annually.
VI. OUTREACH DURING A WAITING LIST
When a waiting list is instituted by the state, a local agency cannot decide to not have a waiting list within their district due to caseload problems.
A. Outreach
The USDA and DPH are fully committed to the principle of integrating WIC and health and social services while protecting the individual's right to privacy.
B. Coordination With Government Entitlement Program
During the WIC application and certification process, WIC staff refers

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GA WIC 2010 PROCEDURES MANUAL

Outreach

families as appropriate and collects data on participation in other governmental entitlement programs, e.g. Medicaid, Food Stamps and Temporary Assistance for Needy Families (TANF).

VII. PROGRAM COSTS
Costs of promotional efforts designed to encourage and increase participation in the WIC Program are reimbursable. Outreach efforts should be consistent with the health-oriented nature of the WIC Program.
VIII. COORDINATION/INTEGRATION OF SERVICES
A. Outreach
Integration of WIC services with other health clinic services has been a major thrust for the State WIC Program and the Division of Public Health. All districts have taken positive steps toward decentralization and the integration of WIC with existing services. (Attachment OR-1)
B. WIC/Medicaid Coordination
To date several measures have been implemented statewide to address the coordination of the WIC and Medicaid Programs. They include: 1. The WIC Certification process now uses the WEB portal for
adjunctive eligibility. The toll free number for Georgia WIC Program is 1-800-228-9173.
2. The State of Georgia "Right From The Start Medicaid (RSM)" program provides medical assistance to pregnant women and children ages 0 through 18 years. The toll free number for Georgia Medicaid Program is 1-800-809-7276.
3. The Georgia Association for Primary Healthcare, Inc's Community based Health Centers provides health and nutrition services, including WIC services in some areas (Attachment OR-2).
C. WIC Coordination Strategies
Coordination Strategies Handbook A Guide for WIC and Primary Care Professionals, development of this handbook was funded through a grant from the Food and Nutrition Service (FNS), U.S. Department of

OR-4

GA WIC 2010 PROCEDURES MANUAL

Outreach

Agriculture, for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This project was one of a number of activities undertaken in response to the 1994 legislative mandate for enhanced coordination between the WIC Program and health services. The legislation , the Healthy Meals for Healthy Americans Act (Public Law 103-448), stipulated that the Secretaries of Agriculture and Health and Human Services jointly establish and carry out initiatives to provide WIC services at substantially more Community and Migrant Health Centers (C/MHCS) (Attachment OR-3) and improve coordination of WIC services with Indian Health Services (HIS) facilities. This publication can be found online at: http://wwwfns.usda.gov/WIC/resources/coordinationstrategies.htm.
D. WIC Works Resources Center
The WIC Resources Center is a USDA sponsored site in which states share State developed materials. This information can be accessed online at: http://www.nal.usda.gov/wicworks/.
The site consists of: WIC Learning Online, a series of 12 online learning modules designed for all levels of staff working in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC Database, online, searchable database of materials developed for WIC audiences. WIC Sharing Center WIC Learning Center WIC Topics A-Z WIC Talk
E. Georgia WIC Program Facts Information Sheet

Why is WIC Important?
Georgia has one of the highest infant mortality rates in the nation. Good nutrition and regular prenatal care during pregnancy, and good nutrition and preventive healthcare for infants is key to preventing babies from dying or becoming disabled.
Low-income women in Georgia who receive both WIC and Medicaid health insurance have a significantly lower infant mortality rate than do other low-income women in the state. They are more likely to get

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GA WIC 2010 PROCEDURES MANUAL

Outreach

prenatal care early in their pregnancy and to seek preventive care, such as immunizations, for their children.
Every dollar spent on WIC saves up to three dollars in healthcare costs, according to a national study.
Who Gets WIC?
To be certified as eligible for the Program, infants, children, and pregnant, postpartum, and breastfeeding women must meet all of the following eligibility requirements:
x Categorical x Residential x Income x Nutrition Risk
Categorical Requirement
The following individuals are considered categorically eligible for WIC: prenatals, breastfeeding (up to 1 year), post partum (up to 6 months), children ages (1-5) and infants (0-12 months).
Residential Requirement
Applicants must live in Georgia (Attachment OR-4). Applicants served in areas where WIC is administered by an Indian Tribal Organization (ITO) must meet residency requirements established by the ITO. As a State agency option, applicants may be required to live in a local service area and apply at a WIC clinic that serves that area. Applicants are not required to live in the state or local service area for a certain amount of time in order to meet the WIC residency requirement. Income Requirement
To be eligible for WIC, applicants must have income at or below an income level or standard set by the State agency or be determined automatically income-eligible based on participation in certain programs.
Nutrition Risk Requirement
Applicants must be seen by a health professional such as a physician, nurse, or nutritionist who must determine whether the individual is at nutritional risk. In many cases, this is done in the WIC clinic at no cost to the applicant. However, this information can be obtained from another

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GA WIC 2010 PROCEDURES MANUAL

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health professional such as the applicants' physician.

"Nutrition risk" means that an individual had medical-based or dietarybased conditions. Examples of medical-based conditions include anemia (low blood levels), underweight, or history of poor pregnancy outcomes. A dietary-based condition includes, for example, a poor diet.

At a minimum, the applicant's height and weight must be measured and blood work taken to check for anemia.

An applicant must have at least one of the medical or dietary conditions on the State's list of WIC nutrition risk criteria.

Women wishing to apply for WIC benefits for themselves or their children should contact their local health departments. In Atlanta, WIC applicants may also apply at Grady Hospital and Southside Healthcare, Inc.

Income Eligibility Guidelines effective July 1, 2009 June 30, 2010:

Family Size 1 2 3 4 5 6 7 8 Each Additional Member Add

Yearly Income 20,036 26,955 33,874 40,793 47,712 54,631 61,550 68,469 +6,919

Length of Participation

WIC is a nutrition education, supplemental food, and referral program which is designed to enhance the nutritional status of women, infants, and children. A certification period is the length of time a WIC participant is eligible to receive benefits. An eligible individual usually receives WIC benefits from 6 months to a year, at which time she/he must reapply.

Moving

WIC participants who move from one area of the state to another are placed at the top of a waiting list when they move and are served first when the WIC agency can serve more individuals. WIC participants who move can continue to receive WIC benefits until their certification period

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GA WIC 2010 PROCEDURES MANUAL

Outreach

expires as long as there is proof that the individual received WIC benefits in another area or state. Before a participant moves, they should tell the WIC office. In most cases, WIC staff will give the participant a special card, which proves that the individual participated in the WIC Program. When the individual moves, they can call the new WIC office for an appointment and take the documentation to the WIC appointment in the new area or State.
Waiting List / Priority System
Sometimes WIC agencies do not have enough money to serve everyone who needs WIC or calls to apply. When this happens, WIC agencies must keep a list, called a waiting list, of individuals who want to apply and are likely to be served. WIC agencies then use a special system, called Priority System, to determine who will get WIC benefits first when more people can be served. The purpose of the priority system is to make sure that WIC services and benefits are provided first to participants with the most serious health conditions such as low hemoglobin/hematocrit, underweight, or history of problems during pregnancy.

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GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1

IMPORTANT: Clinics vary in range of services provided. Please contact the main site or the clinic(s) in which you are interested to verify the type of services offered as well as location and hours of operation.

Main Site

Address

City, State, ZIP

Phone

Albany Area Primary 204 N. Westover

Health Care, Inc

Boulevard

Albany, GA 31707

(229) 888-6559

Clinics
East Albany Medical Center
East Albany Pediatric & Adolescent Center
Rural HIV Model
Dawson Medical Center
Edison Medical Center
Lee Medical Arts Center
Baker County Primary Health Care Center

1712-A East Broad Albany, GA

Avenue

31705

1712-C East Broad Albany, GA

Avenue

31705

2202 East Oglethorpe Boulevard

Albany, GA 31705

420 Johnson Street, Dawson, GA

S.E.

39842-1523

19519 West Hartford Street

Edison, GA 31746-0849

235 Walnut Street

Leesburg, GA 31705

100 Sunset Boulevard

Newton, GA 39870

(229) 639-3100 (229) 639-3103 (229) 431-1423 (229) 995-2990 (229) 835-2238 (229) 759-6508 (229) 734-5250

Notes

Service Types

Admin Only

Primary Medical Care

BPHC Supported Programs
CHC, ISDI

Year round
Year round
Year round
Year round
Year round
Year round
Year round

OR-9

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Southside Medical Center, Inc
Clinics
Southside Medical Center, Inc Atlanta Southside Medical Center, Inc Thomasville Heights Satellite Clinic Southside Medical Center, Inc Gresham

Address
1046 Ridge Avenue, Southwest
1660 Lakewood Avenue Apartment 143144 1178 Henry Thomas Drive 2578 Gresham Road

City, State, ZIP

Phone

Notes

Atlanta, GA 30315

(404) 6881350

Admin/ Clinic

Atlanta, GA 30315

(404) 6271385

Year round

Atlanta, GA 30315

(404) 6220727

Year round

Atlanta, GA 30316

(404) 2412336

Year round

Service Types

BPHC Supported Programs

Dental Care Services,

Enabling Services,

Mental

Health/Substance

Abuse Services,

Obstetrical and

CHC

Gynecological Care,

Other Professional

Services, Primary

Medical Care,

Specialty Medical Care

OR-10

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
West End Medical Centers, Inc
Clinics Bowen Homes
Herndon Homes
West End Medical Center West End Medical Center at West Lake West End Medical Center at John O Chiles

Address

City, State, ZIP

868 York Atlanta, Avenue, GA Southwest 30310

950 Wilkes Circle

Atlanta, GA 30318

511 Johns Street

Atlanta, GA 30318

868 York Avenue, SW

Atlanta, GA 30318

319 West Lake Avenue, NW

Atlanta, GA 30318

456 Ashby Street

Atlanta, GA 30310

Phone
(404) 756-8732
(404) 794-0851 (404) 572-5850 (404) 752-1400 (404) 752-1450 (404) 753-1970

Notes
Admin/ Clinic
Year round Year round Year round
Year round
Part time

Service Types

BPHC Supported Programs

Dental Care Services, Enabling Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC, PH

OR-11

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes Service Types

BPHC Supported Programs

Southside Medical Center, Inc

1039 Ridge Avenue, Southwest

Atlanta, GA 30315

(404) 688-1350

Admin/ Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC

Clinics

Southside Medical Center, Inc - Norcross

5139 Jimmy Carter Boulevard

Norcross, GA 300931638

(770) 613-0070

Year round

Bowman Medical Center

206 East Church Street PO Box 430

Bowman, GA 30624

(706) 245-7361

Year round

Gainesville

810 Pine

Medical Center Street

Gainesville, GA 30503

(770) 287-0290

Year round

Hartwell Medical Center

127 West Gibson Street

Hartwell, GA 30643

(706) 376-6100

Year round

OR-12

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Northeast Health Systems, Inc
Clinics
Bowman Medical Center
Gainesville Medical Center Hartwell Medical Center
Lavonia Medical Center
Oglethorpe Medical Center
Georgia Pines Medical Center

Address
11 Charlie Morris Road PO Box 459
206 East Church Street PO Box 430
810 Pine Street
127 West Gibson Street 12134 Augusta Road PO Box 749 247 Union Point Street PO Box 264
123 Gordan Street

City, State, ZIP

Phone

Notes

Colbert, GA 30628

(706) 788-3234

Admin/ Clinic

Bowman, GA 30624

(706) 245-7361

Year round

Gainesville, GA 30503

(770) 287-0290

Year round

Hartwell, GA 30643

(706) 376-6100

Year round

Lavonia, GA 30673

(706) 356-2223

Year round

Lexington, GA 30648

(706) 743-8171

Year round

Washington, GA 30673

(706) 678-1411

Year round

Service Types

BPHC Supported Programs

Primary Medical CHC Care

OR-13

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Valley Healthcare System, Inc
Clinics Martin Luther King, Jr Elementary School Clinic Benning Drive Clinic

Address
Building No 120 1440 Benning Drive
3050 30th Avenue Building #120 1440 Benning Drive

City, State, ZIP

Phone

Notes

Columbus, (706)

Admin/

GA 31903 322-9456 Clinic

Service Types

BPHC Supported Programs

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC

Columbus, GA 31903

(706) 683-7816

Seasonal

Columbus, (706)

Year

GA 31903 689-1331 round

Main Site
Georgia Highlands Medical Services, Inc Clinics

Address
260 Elm Street PO Box 307

City, State, ZIP

Phone

Notes

BPHC
Service Types Supported
Programs

Cumming, GA 30028

(770) 8871668

Admin/Clinic

Primary Medical Care

CHC

OR-14

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Palmetto Health Council, Inc
Clinics
Community Medical Center of Barnesville
Community Medical Center of Hogansville Community Medical Center of Palmetto Community Medical Center of Zebulon
Community Medical Center of Carrollton

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Suite 200 547 Ponce de Leon Ave

Atlanta, GA (404) 92930308-1880 8824

Admin Only

Enabling Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

Suite 1 101 Commerce Place

Barnesville, (770) 358GA 30204 4408

200 N Hwy 29

Hogansville, (706) 675GA 30230 3481

507 Park Palmetto, (770) 463-

Street

GA 30268 4644

1601 Barnesville Street

Zebulon, GA 30295

(770) 5673323

115 Ambulance Drive

Carrollton, GA 30117

(770) 8342255

Year round
Year round
Year round
Year round

Main Site Tendercare Clinic Clinics

Address 803 South Main Street

City, State, ZIP
Greensboro, GA 30642

Phone Notes

Service Types

BPHC Supported Programs

(706) 453- Admin/Clinic 1201

CHC, CHC

OR-15

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

Georgia Mountains 75 Bypass Road Health Services, Inc PO Box 540

Clinics

Georgia Mountains Health Services, Inc

Suite 101 526 Maddox Drive

City, State, ZIP

Phone

Morganton, (706) 374GA 30560 6898

Ellijay, GA (706) 635-

30540

6898

Notes
Admin/ Clinic
Year round

Service Types

BPHC Supported Programs

Primary Medical CHC Care

Main Site

Address

South Central Primary 357 Cargile Road

Care Center No 1

PO Box 749

Clinics
South Central Primary Care Center, Inc
South Central Primary Care Center No 3
South Central Primary Care Center No 2
South Central Primary Care Center

2016 Ocilla Rd
200 South Cherry Street
202 South Cherry Street
105 Fleet Wood Avenue

City, State, ZIP

Phone

Notes

Ocilla, GA (229) 468- Admin/

31774

9160

Clinic

Service Types
Obstetrical and Gynecological Care, Primary Medical Care, Specialty Medical Care

BPHC Supported Programs
CHC

Douglas, (912) 384- Year

GA 31533 2252

round

Ocilla, GA (229) 468- Year

31774

5911

round

Ocilla, GA (229) 468- Year

31774

7762

round

Willacooch ee, GA 31650

(912) 5345993

Year round

OR-16

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Stewart Webster Rural Health, Inc

220 Alston Street PO Box 357

Richland, GA 31825

(229) 8873324

Clinics
Quitman Health Care
Plains Medical Center

41 Old

Georgetown,

School Road GA 39874

107 Main Street PO Box 389

Plains, GA 31780

(229) 3349353
(229) 8247757

Notes Service Types

BPHC Supported Programs

Admin/ Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

Year round
Year round

OR-17

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Oakhurst Medical Centers, Inc
Clinics
Decatur Medical Office

Address

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Stone

(404)

Primary

770 Village Square Drive Mountain, GA 298- Admin/Clinic Medical CHC

30083-3380 8998

Care

1760 Candler Road

Decatur, GA 30032

(404) 286- Year round 2215

Main Site Address

East Georgia Healthcare Center, Inc

316 North Main Street PO Box 807

Clinics

City, State, ZIP Phone Notes Service Types

Swainsboro, GA 30401

(478) 2372638

Admin/ Clinic

Dental Care Services, Mental Health/Substance Abuse Services, Primary Medical Care

BPHC Supported Programs
CHC, MHC

Main Site

Address

Primary Health Care Center of Dade, Inc
Clinics

13570 North Main Street

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Trenton, GA 30752

(706) 6572510

Primary Admin/Clinic Medical CHC
Care

OR-18

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State,
ZIP

Phone

Tri-County Health
System, Inc

140 Norwood
Road
PO Box 312

Warrenton, GA (706) 465-

30828

3253

Clinics

Tri-County
Health System, Inc

156 Alexander Crawfordville, (706) 456-

Street

GA 30631

2925

Tri-County
Health System, Inc

437-C East
Main Street

Gibson, GA
30810

(706) 598-
3359

Hancock County
Primary Health Care

323 Hamilton
Street
PO Drawer J

Sparta, GA
31087

(706) 444-
5241

Notes

BPHC
Service Types Supported
Programs

Admin/
Clinic

Dental Care Services, Obstetrical and Gynecological Care, Primary
Medical Care

CHC

Year
round
Year
round
Year
round



Main Site

Address

City, State,
ZIP

Phone

Notes

Service
Types

BPHC Supported Programs

McKinney Community
Health Center, Inc

218 Quarterman
Street
PO Box 1902

Waycross,
GA 31501-
3547

(912) 287-0301

Admin/
Clinic

Dental Care Services, Enabling Services, Other Professional Services, Primary Medical
Care

CHC,
MHC

Clinics

McKinney
Community Health Center, Inc

122 North Main
Street

Nahunta, GA
31553

(912) 462-6222

Year
round

McKinney
Community Outreach Center

935 McDonald
Street

Waycross,
GA 31501

(912) 285-5080

Year
round

OR-19

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Community Health
Care Systems, Inc
Clinics
Tennille
Community Health Center

Address
508 West Elm Street
PO Box 371

City, State,
ZIP
Wrightsville,
GA 31096

Phone Notes

(478) 864- Admin/

2600

Clinic

Service Types
Obstetrical and Gynecological Care, Primary
Medical Care

BPHC Supported Programs
CHC

116 Smith Street

Tennille, GA
31096

(478) 552- Year

7384

round

Related Primary Care References Go to Bureau of Primary Health Care (BPHC) Go to Health and Human Services (HHS) | Go to Health Resources and Services Administration (HRSA)
/DVWUHYLVHG0DU

OR-20

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

Georgia's Community Based Health Center Practices
Albany Area Primary Health Care, Inc.
204 N. Westover Blvd. Albany, GA 31707 (229) 888-6559 (229) 436-4107/FAX Tary L. Brown, CEO Linda Leeson, COO Bernard Scoggins, M.D., Medical Director Dougherty County
Baker County Health Center 100 Sunset Boulevard./P.O. Box 130 Newton, GA 31770 (229) 734-5250 (229) 734-5606/FAX Baker County
Dawson Medical Center 420 Johnson Street Dawson, GA 39842 (229) 995-2990 (229) 995-2993/FAX Terrell County
East Albany Medical Center 1712-A East Broad Avenue/ P.O. Box 50098 Albany, GA 31705/31703 (229) 639-3100 (229) 888-6516/FAX Dougherty County
East Albany Pediatric & Adolescent Center 1712-C East Broad Avenue/P.O. Box 50098 Albany, GA 31705/31703 (229) 639-3103 (229) 888-8935 Dougherty County

Edison Medical Center 19159 West Hartford Street/P.O. Box 849 Edison, GA 31746-0849 (229) 835-2238 (229) 835-3032/FAX Calhoun County
Lee Medical Arts Center 235 Walnut Street Leesburg, GA 31763 (229) 759-6508 (229) 759-9950/FAX Lee County
Rural HIV Model 2202 E. Oglethorpe Blvd. Albany, GA 31705 (229) 431-1423 (229) 438-0738/FAX Dougherty County
Athens Neighborhood Health Center
675 College Avenue/P.O. Box 147 Athens, GA 30603 (706) 546-5526 (706) 546-5687/FAX Diane Dunston, M.D., Chief Executive Officer & Medical Director Clarke County
East Athens Satellite 402 McKinley Drive/ P.O. Box 81102 Athens, GA 30603/30608 (706) 543-1145 Clarke County
Community Health Care Systems, Inc.
508 West Elm Street/P.O. Box 371 Wrightsville, GA 31096 (478) 864-2600 (478) 864-2244/FAX Carla Belcher, Chief Executive Officer Dale Brown, M.D., Medical Director Johnson County

OR-21

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2 (cont'd)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

Tennille Community Health Center 116 Smith Street Tennille, GA 31089 (478) 552-7384 (478) 552-1198/FAX Washington County
East Georgia Healthcare Center, Inc.
316 North Main Street/P.O. Box 807 Swainsboro, GA 30401 (478) 237-2638 (478) 237-9138/FAX Jennie Wren Denmark, Chief Executive Officer Sanjay Serrao, M.D., Medical Director Emanuel County
Georgia Highlands Medical Services, Inc.
260 Elm Street/P.O. Box 307 Cumming, GA 30040/30028 (770) 887-1668 (770) 781-9937/FAX Carlos Stapleton, Chief Executive Officer Ellie Campbell, D.O., Medical Director Forsyth County
Georgia Mountains Health Services, Inc.
GA Mountains Health Services at Morganton 75 ByPass Road, P.O. Box 540 Morganton, GA 30560 (706) 374-6806 (706) 374-5006/FAX Bruce Whyte, M.D., Chief Executive Officer Lajos Toth, M.D., Medical Director Fannin County
GA Mountains Health Services at Ellijay 526 Maddox Drive, Suite 101 Ellijay, GA 30540 (706) 635-6898 (706) 635-6888/FAX Gilmer County

McKinney Community Health Center
218 Quarterman Street/ P.O. Box 1902 Waycross, GA 31502 (912) 287-9140 (912) 287-0301 (CEO) (912) 287-1059/FAX Ola Smith, CEO Mukesh Agarwal, M.D., Medical Director Ware County
McKinney Community Outreach Center 935 McDonald Street Waycross, GA 31501 (912) 285-5080 Ware County
McKinney Community Health Center, Inc. 122 North Main Street Nahunta, GA 31553 (912) 462-6222 (912) 462-6803/FAX Brantley County
Northeast Health Systems, Inc.
Corporate Office 11 Charlie Morris Road./P.O. Box 459 Colbert, GA 30628 (706) 788-3234 (706) 788-2936/FAX Jackie Griffin, D.P.A., Chief Executive Officer Paul Raber, D.O., Medical Director
Bowman Medical Center 206 East Church Street/P.O. Box 430 Bowman, GA 30624 (706) 245-7361 (706) 245-4054/FAX Elbert County
Colbert Medical Center 11 Charlie Morris Road./P.O. Box 609 Colbert, GA 30628 (706) 788-2127 (706) 788-2815/FAX Madison County

OR-22

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2 (cont'd)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

Georgia Pines Medical Center 212 Hospital Drive Washington, GA 30673 (706) 678-1411 (706) 678-3620/FAX Wilkes County
Hartwell Medical Center 127 West Gibson Street Hartwell, GA 30643 (706) 376-6100 (706) 376-3394/FAX Hart County
Lavonia Medical Center 11909 Augusta Road, Suite 8/P.O. Box 749 Lavonia, GA 30553 (706) 356-2223 (706) 356-2959/FAX Franklin County
Oglethorpe Medical Center 247 Union Point Street/P.O. Box 264 Lexington, GA 30648 (706) 743-8171 (706) 743-3000/FAX Oglethorpe County
Greater Hall Community Health Center 810 Pine Street, SW/P.O. Box 445 Gainesville, GA 30503 (770) 287-0290 (770) 287-7597/FAX Hall County
Oakhurst Medical Centers, Inc.
770 Village Square Stone Mountain, GA 30083 (404) 298-8998 (404) 298-7658/FAX William A. Murrain, JD, Chief Executive Officer Doa Harris, M.D., Medical Director Dekalb County

Oakhurst Medical Center at Candler and Glenwood 1760 Candler Road Decatur, GA 30032 (404) 286-2215 Dekalb County
Palmetto Health Council, Inc.
Corporate Office 547 Ponce de Leon Avenue, Suite 200 Atlanta, GA 30308-1880 (404) 929-8824 (404) 929-9769 Jon Wollenzien, Jr., D.B.A., Chief Executive
Community Medical Center of Palmetto 507 Park Street/P.O. Box 469 Palmetto, GA 30268 (770) 463-4644 (770) 463-9885/FAX Fulton County
Community Medical Center of Zebulon 1601 Barnesville Street/P.O. Box 561 Zebulon, GA 30295 (770) 567-3323 (770) 567-0332/FAX Pike County
Community Medical Center of Barnesville 101 Commerce Place, Suite 1 Barnesville, GA 30204 (770) 358-4408 (770) 358-0002/FAX Lamar County
Community Medical Center of Hogansville 200 N Hwy 29 Hogansville, GA 30230-1142 (706) 675-3481 (706) 675-8253/FAX Heard County

OR-23

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2 (cont'd)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

Community Medical Center of Carrollton 115 Ambulance Drive Carrollton, GA 30117-3855 (770) 834-2255
Primary Health Care Center of Dade
13570 North Main Street Trenton, GA 30752 (706) 657-7575 (706) 657-5885/FAX Diana Allen, LCSW, Chief Executive Officer Pamela C. Ventra, M.D., Medical Director Dade County
Saint Joseph's Mercy Care Services
60 11th Street, NE Atlanta, GA 30309 (404) 249-8600 (404) 249-8941/FAX Paul Bolster, President Noemi Carcar, M.D., Medical Director Fulton County

101 Bowens Mill Road Douglas, GA 31533 (229) 384-2252 (229) 384-8888/FAX Coffee County
South Central Primary Care Center Fleetwood Avenue Willacoochee, GA 31650 (912) 534-5993 (912) 534-5703/FAX Atkinson County
South Columbus, Inc., Community Health Center of
1315 DeLaunay Avenue, Suite 201 Columbus, GA 31901 (706) 322-9599 (706) 322-8332/FAX Sarah Lang, Chief Executive Officer & Medical Director Muscogee County

Central Health Center 201 Washington Street Atlanta, GA 30303 (404) 659-0117 (404) 221-3692/FAX Fulton County
South Central Primary Care Center, Inc.
357 Cargile Road/P.O. Box 749 Ocilla, GA 31774 (229) 468-9160 (229) 468-5526/FAX Delane Roberts, Chief Executive Officer Saiyed Ashfaq, M.D., Medical Director Irwin County
South Central Primary Care Center 200 Cherry Street Ocilla, GA 31774 (229) 468-5911/ (229) 468-4247/FAX (229) 468-7762/(229) 468-9302/FAX Irwin County
South Central Primary Care Center

South Columbus Community Health Center 1440 Benning Drive - Building 120 Columbus, GA 31903 (706) 689-1331 (706) 689-4340/FAX Muscogee County
MLK School-based Clinic 305 30th Avenue Columbus, GA 31903 (706) 683-7816 Muscogee County
Southside Medical Centers, Inc.
1039 Ridge Avenue, SW Atlanta, GA 30315 (404) 688-1350 (404) 688-2962/FAX David M. Williams, M.D., Chief Executive Officer Dominic Mack, M.D., Medical Director Fulton County
SMC Substance Abuse Treatment Center

OR-24

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2 (cont'd)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

1660 Lakewood Avenue, SW Atlanta, GA 30316 (404) 627-1385 (404) 622-9769/FAX Fulton County

Southside Medical Center Gresham/DeKalb Office 2578 Gresham Road Atlanta, GA 30316 (404) 241-2336 (404) 241-6256/FAX DeKalb County

Southside Medical Center Thomasville Office 1178 Henry Thomas Drive Apt# 143 and Apt# 144 Atlanta, GA 30315 (404) 622-0727 (404) 627-8420/FAX Fulton County

SMC Clinica de la Mama
1039 Ridge Avenue, SW Atlanta, GA 30315 (404) 688-1350 Fulton County

Clinica de la Mama Austell 1680 Mulkey Road, Suite E Austell, GA 30106 (770) 732-1880 Cobb County

Clinica de la Mama Norcross 5139 Jimmy Carter Boulevard, Suite 205 Norcross, GA 30093 (770) 613-0070 Gwinnett County

Clinica de la Mama South Atlanta/Cleveland 2685 Metropolitan Parkway, Suite C Atlanta, GA 30048 (404) 684-1250 Fulton County

Stewart-Webster Rural Health, Inc.
220 Alston Street Richland, GA 31825 (229) 887-3324 (229) 887-2559/FAX Sarah Richardson, Chief Executive Officer George Ellard M.D., Medical Director

OR-25

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2 (cont'd)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

Stewart County
Lumpkin Health Care 102 Cotton Street/P.O. Box 488 Lumpkin, GA 31815 (229) 838-4150 (229) 838-4156/FAX Stewart County
Plains Medical Center 107 Main Street/P.O. Box 389 Plains, GA 31780 (229) 824-7757 (229) 824-3497/FAX Sumter County
Quitman Health Care 41 Old School Road/ P.O. Box 584 Georgetown, GA 39854 (912) 334-9353 Quitman County
Tender Care Clinic, Inc.
803 South Main Street Greensboro, GA 30642 (706) 453-1201 (706) 453-1205/FAX Lisa Brown, R.N., Executive Director Medical Director Greene County
Tri-County Health System, Inc.
140 Norwood Road/P.O. Drawer 312 Warrenton, GA 30828 (706) 465-3253 (706) 465-3256/FAX Donna Newsome, Chief Executive Officer Debra Crawley, M.D., Medical Director Warren County

Tri-County Family Medical Center 437 East Main Street/P.O. Box 234 Gibson, GA 30810 (706) 598-3359 (706) 598-3403/FAX Glascock County
Hancock County Primary Health Care Center 323 Hamilton Street/P.O. Box J Sparta, GA 31087 (706) 444-5241 (706) 444-7302/FAX Hancock County
West End Medical Centers, Inc.
868 York Avenue Atlanta, GA 30310 (404) 752-1400/(404) 755-8295/FAX (404) 756-8732 (CEO)/(404) 752-7296/FAX CEO) Daisy S. Harris, Chief Executive Officer Linda J. Cannon, M.D., Medical Director Fulton County

Tri-County Family Medical Center 156 Alexander Street/P.O. Box 205 Crawfordville, GA 30631 (706) 456-2925 (706) 456-2224/FAX Taliaferro County

OR-26

GA WIC 2010 PROCEDURES MANUAL

Attachment OR-2 (cont'd)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

West End Medical Centers at Bowen Homes 950 Wilkes Circle, N.W. Atlanta, GA 30318 (404) 799-0851 (404) 794-4798/FAX Fulton County

West End Medical Centers at Herndon Homes 511 John Street Atlanta, GA 30318 (404) 572-5850 (404) 880-9071/FAX Fulton County

West End Medical Group 361 North Marietta Pkwy Marietta, GA 30062 (770) 919- 0025 (678) 569-0228/FAX Cobb County

OR-27

GA WIC 2010 PROCEDURE MANUAL

Attachment OR-3

Georgia Farmworker Health Program Migrant Health Clinic Sites

Project Site & Address
Coffee County Health Department 1111 West Baker Highway Douglas, Georgia 31533-4920

Project Coordinator Josie Haklin, RN

Contact Information
Tel: 912-389-4458 Fax: 912-389-4326 kkhulett@gdph.state.ga.us

Decatur County Health Department 928 West Street PO Bos 417 Bainbridge, Georgia 39818

Sherrie Hutchins, RN, Director

Tel: 229-248-3055 Fax: 229-248-3010 slhutchins@dhr.state.ga.us

Ellaville Primary Medicine Clinic 103 Broad Street PO Box 65 Ellaville, Georgia 31806-9428

Mary Anne Shepherd, RN-C, FNP

Tel: 229-937-5321 Fax: 229-937-2232 mshepherd@sumterregional.org

Ellenton Clinic 185 Baker Street PO Box 312 Ellenton, Georgia 31747

Cynthia Hernandez

Tel: 229-324-2845 Fax: 229-324-3383 cyhernandez@dhr.state.ga.us

Georgia Farmworker Clinic J. Frank Culpepper Road PO Box 889 Lake Park, Georgia 31636

Steve Graham, President/CEO

Tel: 229-242-9003 Fax: 229-242-0490 stgraham@mchsi.com

Rochelle Healthcare Center 636 2nd Avenue SW
PO Box 481
Rochelle, Georgia 31079

H. Scott Jobe, MBA, CMPE

Tel: 229-365-2570 (Clinic) Fax: 229-365-2571 (Clinic) Scott Jobe: Tel: 229-271-4676 hsjobe@crispregional.org

Tattnall County Health Department 1001 N. Downing Musgrove Highway Glennville, Georgia 30427

Sandra Durrence, FNP

Tel: 912-654-5300 Fax: 912-654-5303 smdurrence@gdph.state.ga.us

Office of Rural Health Services

OR- 28

GA WIC 2010 PROCEDURES MANUAL District Map

Attachment OR-4

OR-29

GA WIC 2010 PROCEDURES MANUAL

Food Delivery

TABLE OF CONTENTS

Page

I.

General...................................................................................................................... FD-1

II.

Types of WIC Vouchers .........................................................................................FD-1

A. Vouchers Printed On Demand (VPOD).........................................................FD-2

B. Blank Manual Vouchers ...................................................................................FD-2

C. Preprinted Standard Manual Vouchers.........................................................FD-2

D. Vegetable and Fruit Voucher ..........................................................................FD-3

E. WIC Farmers Market Nutrition Program (FMNP) ......................................FD-3

F. Senior Farmers Market Nutrition Program Vouchers.................................FD-3

III. Voucher Issuance General ..................................................................................FD-3

A. Valid Certification Period ................................................................................FD-3

B. Identification of Person Picking Up Vouchers..............................................FD-4

C. Corrections .........................................................................................................FD-5

D. Issuance ..............................................................................................................FD-5

E. Categorically Ineligible ....................................................................................FD-6

F. Issuance of Vouchers to Family Members.....................................................FD-7

IV. Voucher Printed on Demand (VPOD) and Computer Generated Vouchers ...............................................................................................FD-7

A. Data Elements....................................................................................................FD-7

B. Voucher Cycles .................................................................................................FD-8

C. Voucher Packaging ...........................................................................................FD-8

D. Voucher Issuance ..............................................................................................FD-9

E. Transporting VPOD Vouchers from a Site within a Site...........................FD-11

F. Ordering VPOD Vouchers.............................................................................FD-11

GA WIC 2010 PROCEDURES MANUAL

Food Delivery

V.

Manual Vouchers (Blank and Standard) ...........................................................FD-11

A. Blank Manual Vouchers .................................................................................FD-11

B. Preprinted Manual Vouchers ........................................................................FD-12

C. Ordering Manual Vouchers...........................................................................FD-12

D. Receipt of Manual Vouchers .........................................................................FD-12

E. Inventory Control of Manual Vouchers.......................................................FD-13

F. Issuance of Manual Vouchers .......................................................................FD-14

G. Distribution of Manual Voucher Copies .....................................................FD-14

H. Voided Manual Vouchers ..............................................................................FD-15

VI. VPOD Procedures .................................................................................................FD-16

A. General..............................................................................................................FD-16

B. Issuing VPOD Vouchers ................................................................................FD-17

C. Voucher Reconciliation ..................................................................................FD-17

D. VPOD Inventory Log Sheets .........................................................................FD-18

E. Corrective Actions for VPOD........................................................................FD-18

VII. Mailing/Delivery of WIC Vouchers ..................................................................FD-19

A. Conditions for Mailing/Delivering Vouchers ............................................FD-19

B. Acceptable Reasons for Mailing/Delivering Vouchers.............................FD-19

C. Mailing/Delivery Procedures .......................................................................FD-19

D. Voucher Mailing Process ...............................................................................FD-21

E. Returned Vouchers .........................................................................................FD-21

VIII. Prorated Vouchers ................................................................................................FD-21

IX. Late Pick-Up of Vouchers ....................................................................................FD-22

X.

Coordination of Health Services and Vouchers Issuance ...............................FD-23

GA WIC 2010 PROCEDURES MANUAL

Food Delivery

XI. Lost, Stolen or Damaged Vouchers ....................................................................FD-24 A. Replacement of Vouchers ..............................................................................FD-24 B. Lost/Stolen/Destroyed/Voided Voucher Report .....................................FD-24 C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance .............................FD-25 D. Change of Formula Order/Formula Purchased In Error .........................FD-26
XII. Borrowed Vouchers ..............................................................................................FD-27 XIII. Critical Errors ........................................................................................................FD-27 XIV. Cumulative Unmatched Redemption Report (CUR).......................................FD-28
A. Introduction .....................................................................................................FD-28 B. Procedures for Reconciliation .......................................................................FD-28 C. Manually Reconciling CUR Part 1................................................................FD-29 D. Manually Reconciling CUR Part 2................................................................FD-32 E. Procedures for Both Reports .........................................................................FD-33 XV. Unmatched Redemption Report.........................................................................FD-33 XVI. Reconciliation of WIC Reports and Daily Program Operations .............................................................................................................. FD-33 A. Daily Verifications ..........................................................................................FD-34 B. Monthly Verifications.....................................................................................FD-34
Attachments: FD-1 Preprinted Standard Manual Voucher...............................................................FD-35 FD-2 Blank Manual Voucher.........................................................................................FD-36 FD-3 Voucher Printed On Demand (VPOD) Voucher ..............................................FD-37 FD-4 WIC Farmer Market Nutrition Program Check ..............................................FD-38 FD-5 Senior Farmers Market Nutrition Program Check...........................................FD-39

GA WIC 2010 PROCEDURES MANUAL

Food Delivery

FD-6 Voucher Cycle Packing List.................................................................................FD-40 FD-7 Form and Manual Voucher (Order Supply Form) ...........................................FD-41 FD-8 Manual Voucher Inventory .................................................................................FD-42 FD-9 Voucher Printed On Demand Log Sheet ...........................................................FD-43 FD-10 Batch Control Form...............................................................................................FD-44 FD-11 Batch Control Exception Report .........................................................................FD-45 FD-12 Georgia WIC Program Identification Card .......................................................FD-46 FD-13 Daily Roster/Monthly Mailed Voucher Report ...............................................FD-47 FD-14 Borrowed Voucher Report Form ........................................................................FD-48 FD-15 Cumulative Unmatched Redemptions Part I....................................................FD-49 FD-16 Cumulative Unmatched Redemptions Part II ..................................................FD-50 FD-17 Unmatched Redemption Report.........................................................................FD-51 FD-18 Lost, Stolen, Destroyed, Voided Voucher Report ............................................FD-52 FD-19 Vouchers Printed on Demand (VPOD) Receipt ...............................................FD-53

GA WIC 2010 PROCEDURES MANUAL

Food Delivery

I. GENERAL
The Georgia WIC Program uses a uniform retail food delivery system. Participants are issued Food Instruments (vouchers or FI) which are redeemed at authorized vendors for WIC foods. Clinics issue vouchers to participants, or their proxies, on a one, two, or three-month interval. Georgia has a fully automated food delivery and management information system. The Georgia WIC Program contracts with a third party data processing firm, CSC, (formerly Covansys) located in Lenexa, Kansas. CSC maintains the participant master file, produces a wide range of monthly and quarterly reports and performs reconciliation of all issued food instruments. Local agencies electronically transmit WIC voucher issuance records to CSC daily.
Participants redeem the vouchers for specified types and quantities of foods at authorized vendors. Vendors then deposit the redeemed vouchers into their local bank accounts just as they would any other check. The vouchers proceed through the banking system to a central clearing bank where they are edited for missing or invalid information. Vouchers that are not paid are returned to the bank of first deposit and the vendor's account is reduced by the value of the vouchers. Vendors may request payment for returned vouchers by submitting them along with a completed Returned Voucher Payment log to the Georgia WIC Program. Vouchers paid, but flagged as suspect, are investigated by the State agency.
In February 2008, the Georgia WIC Program initiated the Automated Clearing House (ACH) process for making payments for vouchers presented with a requested value over the maximum allowable cost.
When such a voucher reaches the bank, it will be immediately paid at a rate equal to the average for that voucher for the vendor's peer group.
While those vouchers must still be returned to the bank of first deposit and a return check fee imposed, ACH greatly reduces the time and expense involved in paying over the maximum rejected vouchers.
CSC reconciles individually issued and redeemed vouchers as required by federal regulations and maintains a voucher master file that tracks the status of all vouchers. CSC also produces participation, financial, vendor, and other management reports at regular intervals for use by State and local agencies.
II. TYPES OF WIC VOUCHERS
There are six (6) types of WIC vouchers that may be issued to participants:
FD-1

GA WIC 2010 PROCEDURES MANUAL

Food Delivery

A. Vouchers Printed On Demand (VPOD)
Vouchers Printed On Demand (VPOD) are produced on site by the clinic's automated system for each qualified participant,(See Attachment FD-3). The receipts generated from printing these vouchers are maintained by the clinic. VPOD serial numbers must be entered into the VPOD inventory log within three (3) days of receipt (See Attachment FD-10).
B. Blank Manual Vouchers
Blank Manual vouchers maybe issued in cases when automated systems are inoperable or otherwise unavailable. These vouchers may be completed for:
1.) New or transferring participants; 2.) To replace voided computer printed vouchers; 3.) To adjust a food package in the event of late pick up by a participant, or 4.) To supplement the preprinted manual voucher food package. (See FD-V., Manual Vouchers and FD-V.,-F. Issuance of Manual Vouchers for procedures). The clinic identification number is preprinted on blank manual vouchers (See Attachment FD-2). These vouchers must be stored in a secure location and must be logged in the Manual Inventory Log within three (3) days of receipt. (See Attachment FD-9)
C. Preprinted Standard Manual Vouchers
Standard Manual Vouchers are produced by CSC in separated sets of four (4) food package types. These vouchers contain a preprinted standard food package (See Attachment FD-1). Standard voucher sets must not be broken to issue single standard vouchers. These vouchers must be stored in a secured location and must be logged in the Manual Inventory log within three (3) days of receipt, (Attachment FD-9). The four types of food packages are:
1. Infants (Food Package 153, 876,051). . 2. Pregnant and Breastfeeding Women (Food Package 404). 3. Postpartum, Non-Breastfeeding Women (Food Package 502). 4. Children (Food Package 603).

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D. Vegetable and Fruit Voucher

Vegetable and Fruit Vouchers are part of the expanded food packages that will become effective on October 1, 2009. The vouchers may be redeemed for fresh vegetables and fruit only. A participant will receive a Vegetable and Fruit voucher in the amount of $6, $8 or $10. If the purchase amount exceeds the amount of the voucher, the participant will be allowed to use cash to make up the difference.

E. WIC Farmers Market Nutrition Program (FMNP)

FMNP coupons are printed in the WIC clinic and issued to participants to allow them to purchase fresh fruit and vegetables from participating Farmers Markets. Coupons Printed On Demand (CPOD) differs from Vegetable and Fruit Vouchers in appearance, value and redemption process (See Attachment FD-4). CPOD coupons may only be redeemed during the FMNP season which runs from approximately May to October of each year. They may not be used in grocery stores.
F. Senior Farmers Market Nutrition Program (SFMNP)
SFMNP coupons are either printed at the clinic or may be pre-printed depending on the clinic's situation (See Attachment FD-5). SFMNP coupons are issued to Senior Citizens over the age of 60. This program is run jointly with the Georgia Department of Aging.

III. VOUCHER ISSUANCE - GENERAL
A. Valid Certification Period
Vouchers may only be issued to participants who are within a valid certification period.

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Valid Certification Periods

Category

Valid Certification Period

Pregnant

From the date of certification until six

(6) weeks after delivery

Post Partum

From the actual date of delivery until six

(6) months after delivery

Children

From the date of certification then every

six (6) months until five (5) years of age

Infants (< six (6) months)

From the date of certification until First

(1) birthday

Infants (> six (6) months)

For a six (6) month period starting from the date of certification.

Vouchers must not be issued past the end of the certification period. The issuance period is six (6) months of vouchers for women and children and up to twelve (12) months of vouchers for infants. Ex: if a participant is certified on January 15 and receives a 3b pickup code, (See Edit's Manual for pick-up codes Field 58) he/she is entitled to receive vouchers through the month of June because he/she has received six (6) months of vouchers, January thru June. An issuance month is defined as vouchers issued to a participant during the month regardless of the number vouchers.

Postpartum woman who are due for recertification are being over issued vouchers. This situation occurs when women are issued vouchers during the prenatal period for two or three month increments that extend beyond their pregnancy period. When they are subsequently recertified as a postpartum woman vouchers are issued for the postpartum period without checking the last voucher issuance date. As a result the woman is being over issued vouchers at the post partum period.

B. Identification of Person Picking Up Vouchers

ID cards must be checked for signatures of participants/proxies:

x If a proxy is picking up vouchers.

x If a participant has not previously had a proxy sign their ID card, the proxy must have a dated note, signed by the participant/parent/ guardian/caretaker, giving him/her the authority to pick up vouchers for the participant.

The proxy/authorized representative must also present acceptable form of

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identification and the WIC ID Card to verify that he/she is the person authorized by the participant to pick up vouchers. (See Edits Manual, Table 31 for proof of identification.)
If a participant/ parent/guardian /caretaker does not possess, or has lost his/her ID card, other identification may be accepted as verification and a new ID card issued.
Proxies may not be issued a new WIC ID card.
A proxy must be at least 16 years old.
If a child is placed in foster care, the Foster parent must bring in guardianship papers from DFACS to confirm the child has been placed in their care before a new WIC ID card or vouchers can be issued. See Edits Manual, Table 33 for proof of identification for Parent/Guardian/Caregiver.)
Documentation of ID for Voucher Pickup
Document the ID of the person picking up the vouchers, not of the participant who receives the vouchers.
1. Voucher Printed on Demand (VPOD) - Document the proof code on the voucher receipt under the user's ID.
2. Manual Vouchers - Document the proof code on the manual voucher under the date the vendor must deposit by on clinic copy only.
C. Corrections
Vouchers must not be corrected or altered. If an error is made during issuance, the voucher(s) must be voided (See FD-V.-4 Voided Manual Vouchers). Correction fluid ("white-out") must not be used on vouchers for any reason.

D. Issuance
Local agencies have the option to issue vouchers to participants' at a one, two, or three-month interval. With two or three- month issuance, clinic staff must explain to participants not to use vouchers prior to the "First Day to Use" date on the vouchers.

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E. Categorically Ineligible

Categorically ineligible refers to the period of time a client is no longer in a valid certification period and therefore is not eligible to receive WIC benefits. Participants who are categorically ineligible are postpartum women at six months postpartum, children who have reached their fifth (5th) birthday and breastfeeding women who stop breastfeeding and are (greater than or equal to) six (6) months postpartum or up to 12 months postpartum.
Benefit issuance periods are measured by month, one week at a time, starting with the first date of certification and ending with the last date of eligibility, i.e. the termination date. If the termination date occurs before a full week ends the participant is eligible for benefits for that entire week. For example: If a participant is eligible for vouchers for one or more days within the week, the participants should receive vouchers for that entire week.
When a participant becomes categorically ineligible before the end of the month, they will only receive vouchers up to the categorical term date, example: If a participant category term date is January 15 and his pick-up is January 2 the participant will only receive two vouchers. If the participant pick-up date is after the category term date the participant will receive no vouchers. Vouchers must not be issued past the month of categorical eligibility. The categorical ineligible message will appear on the voucher receipt for the last set of vouchers one month prior to the termination date.

Category Postpartum NonBreastfeeding Women Breastfeeding Women
Children

Categorical Eligibility Six (6) months postpartum from delivery date
Twelve (12) months postpartum or greater than six (6) months postpartum if breastfeeding stops. Fifth (5) Birthday

Last Voucher Issuance Up to week that includes the categorical termination date. Up to week that includes the categorical termination date.
Up to the end of the month that the child turns five (5).

Note: Children should not be recertified in the month they turn five (5) years old. If recertification is due, do not re-certify child, issue vouchers until the end of the month only.

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F. Issuance of Vouchers to Family Members

An employee must never issue vouchers to family members or other persons residing in their household. Family members include but are not limited to:

1. Children 2. Grandchildren 3. Sisters 4. Brothers 5. Nieces 6. Nephews 7. Aunts

8. Uncles 9. Parents 10. Spouses 11. First Cousins 12. In-laws 13. Grandparents 14. Individuals related by marriage

IV. VOUCHER PRINTED ON DEMAND (VPOD) AND COMPUTER GENERATED VOUCHERS
A. Data Elements
The following data elements appear on the face of the vouchers:
1. District/Unit/Clinic. The district is represented by a two-digit number, the unit by a one-digit number, and the clinic by a threedigit number.
2. WIC ID Number. The participant's unique eleven (11) digit identification number that corresponds to the number on the TurnAround Document (TAD). Self-Check Digit. Calculated by the ADP Contractor or front end system. Participant Number (P). This is a one-digit number that specifies an individual family member in a multi-WIC participant family.
3. Participant's Name The full name of the participant (last name, first name, middle initial).
4. First Day to Use (MMDDYY). The first valid date when the voucher may be used to purchase foods.
5. Last Day to Use (MMDDYY). The last valid date, after which the voucher can no longer be used by the participant. The voucher may be used on this date, but not after this date.

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6. Voucher Number. A unique serial number printed on each voucher.
7. Voucher Message. A description of the food items and the quantities that may be purchased. Also, the food package and voucher codes are printed here.
8. WIC Vendor Stamp. Stamped by the vendor prior to deposit. 9. Sign Here At Grocery Store. The participant/proxy signs his/her
name in this space when the voucher is redeemed at a WIC vendor. 10. The reverse side of the vouchers contains an area for endorsement by the authorized WIC vendor location.
B. Voucher Cycles

The clinic staff and participant determine the voucher pickup day. This day is entered as a Pickup Code on the TAD.
Voucher interval codes are entered on the TAD (1= monthly; 2= two months even; 3 = two months odd; 4 = three months).
C. Voucher Packaging In emergency situations where clinics are unable to print vouchers for a period of time, CSC contractor has the capability of producing vouchers. If cases of emergency clinic closing due to natural or man-made disasters, vouchers will be delivered to identified sites, by overnight or ground postal delivery.
Computer printed vouchers are received by the clinic in alphabetical order of the last name of the lead family member within each Sort Code. The lead family member is the one with WIC type P, N, or B or with the lowest Participant ID Number (usually #1).
1. The following items will be transmitted to each clinic (or clinic package #1 if there is more than one [1]). a. Voucher Cycle Packing List The (2-ply) packing list provides the specific beginning and ending voucher numbers for all the computer printed vouchers, manual vouchers when appropriate, and VPOD serial numbers for the clinic. Two copies of the packing list are provided. The clinic must retain one copy and

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send one signed copy to the District office as acknowledgement/proof of receipt of the vouchers.
b. Vouchers
D. Voucher Issuance
The following procedures must be followed when issuing vouchers:
1. Identification. Verify the identity of the person picking up the vouchers. Please refer to FD-III.B. "Identification of Person Picking Up Vouchers," for procedures. Record the ID proof for the person picking up the vouchers in the appropriate place.
2. Vouchers Issuance. Vouchers are only to be issued to participants who are in a valid certification period. (See FD-111. A." Valid Certification Period"). The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name on the vouchers and the receipt must be identical. The following items must be completed on the VPOD receipt each time vouchers are issued:
a. Signature of Participant or Proxy. The participant or proxy must sign his/her name on the signature line to indicate that the proper person has received those specific vouchers. This signature must match the signature of the participant or proxy on the ID card.
(1) Vouchers must not be issued until after the participant/proxy signs the receipt
(2) If a participant or proxy leaves the clinic without signing the receipt, clinic staff must document the issuance by
writing "Failed To Sign". "Failed to sign" must not be abbreviated.
(3) During a monitoring review, if one (1%) percent or more "failed to sign" notations appear on the VPOD receipts in a clinic, a corrective action will be issued to the clinic. Therefore, clinic staff must be extremely careful to ensure that participants sign the VPOD

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receipt every time.
(4) If the participant or proxy is unable to write, he/she must enter his/her mark in lieu of a signature. Clinic staff will print the person's name next to the mark and initial and date, the mark to indicate that it has been witnessed.
3. Voucher Participant/Proxy Signature. The participant or proxy must sign only manual vouchers in the left signature space, in the presence of the issuing staff person.
4. When VPOD vouchers are printed, the printer produces a receipt along with the vouchers. The receipt contains the following information: i. Clients' WIC ID number, ii. Name, iii. Issue date, iv. Last date to use, v. Food package number, vi. Voucher code, vii. Voucher number, viii. Any appropriate message ix. Signature line for the client/proxy to sign. x. Initials of issuing clerk or user ID
The receipt takes the place of the voucher register. The client signs the receipt(s) and only then is handed the vouchers. The receipt must then be immediately filed in numerical order if possible. All receipts must be reconciled with the daily activity report. Any voucher numbers that are missing must have an explanation. "Failed To Print" is not an acceptable explanation.

E. Transporting VPOD Vouchers from a site within a site
When VPOD vouchers are transported to a site that has no printer (voucher issuance clinic only), the vouchers must be printed the afternoon prior to going to the clinic or printed the day of the clinic visit.
Vouchers not issued on site must be voided immediately voided in the system prior to batching for that day.

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See transporting procedures in the Compliance Analysis Section of the Procedures Manual.

F. Ordering VPOD Vouchers
VPOD voucher numbers are received in the clinic from the ADP Contractor CSC. All numbers must be entered on the VPOD inventory log within three (3) days of receipt as with other manual vouchers. For VPOD vouchers, the confirmation notice of voucher numbers sent from CSC will take the place on the packing list but must be maintained in the same manner as the packing list (See Receipt of Manual Vouchers FD-V., D.). The packing list must be signed, dated and a copy sent to the District office within the proper timeframe. Voucher ranges or numbers not issued within thirteen (13) months of receipt will be automatically voided by the system.

V. MANUAL VOUCHERS (Blank and Standard) Manual vouchers are different from VPOD vouchers in the following ways:
1. Manual vouchers are three (3) part forms. The parts are color-coded for distribution as follows:
a. First copy (blue) - participant. b. Second copy (red) - ADP Contractor (or clinic copy if automated
transfer is used.)
c. Third copy (black) serves as clinic proof of issuance.
2. All manual vouchers require completion of participant and issuance data.
3. Blank manual vouchers require entry of food quantities. All blocks must be filled in with a number or an X for those items not assigned.
A. Blank Manual Vouchers
Blank manual vouchers are issued for the following reasons: 1. To provide vouchers for a food package other than those
provided by the preprinted manual vouchers.
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2. To replace one or more vouchers that have been destroyed or damaged. (See Compliance Analysis CA-X).
3. In the event of system failure, loss of power at the clinic or other condition when the clinic system is not available.

B. Preprinted Manual Vouchers
Preprinted Manual Vouchers are issued for the following reasons:
1. To provide vouchers for standard food packages. 2. In the event of system failure, loss of power at the clinic or other
condition when the clinic system is not available.
C. Ordering Manual Vouchers
Local agencies must order manual vouchers from the ADP Contractor. Orders must be made using the "Form and Manual Voucher Orders" Form (Attachment FD-8) and must be received by the ADP Contractor by the 10th or 25th of each month. The ADP Contractor will fill manual voucher orders twice a month and will ship them with each cycle of computer printed vouchers.
D. Receipt of Manual Vouchers
1. Clinic
Clinics will compare beginning and ending voucher numbers to those on the Clinic Voucher Cycle Packing List. Any discrepancies must be reported to the ADP Contractor and the Georgia WIC Program immediately. The packing list must be signed and dated to verify receipt. A copy of the signed/dated packing list must be mailed to the local agency/district office within five (5) days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal Fiscal Year.
2. District/Unit
The District/Unit receives a copy of each detailed clinic-packing list for control, and a summary copy showing total vouchers received from the District/Unit. Any discrepancies must be

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reported to the ADP Contractor immediately. Missing shipments must also be reported to the Georgia WIC Program. All packing list received by the District must be reconciled with the clinic's copy and the District's copy must be signed and dated.

E. Inventory Control of Manual Vouchers
When manual vouchers are received, the serial numbers must be recorded in the "Received" column of the "Manual Voucher Inventory" log (See Attachment FD-9). The numbers must be recorded exactly as is stated on the packing list. This documentation must be completed the same day the vouchers are received by the responsible WIC staff person. Vouchers must be used in the order in which they were received; first in, first out. All vouchers must be used in sequential order until depleted. Do not use two voucher batches at the same time. Complete one batch before using another.
1. Perpetual Inventory (Weekly) (Manual Vouchers)
The perpetual inventory accounts for the voucher numbers issued, voided, and on hand. The perpetual inventory should be conducted daily, and must be done at a minimum weekly and documented on the Manual Voucher Inventory Log Sheet (See Attachment FD-9). If vouchers are issued during the month, a perpetual inventory must be conducted weekly. If no manual vouchers are issued, only a physical inventory is required. All columns of the log must be completed accurately, legibly, and initialed, by a responsible staff member. Always record the voucher numbers immediately after receiving them from the ADP contractor on the Log Sheet.
2. Physical Inventory (Monthly Blank and Standard Manual Vouchers)

A monthly physical inventory of all manual vouchers must be conducted. Another staff person must verify the inventory and initial the inventory log. Physical inventory documentation must include the serial numbers of the vouchers and the total number of vouchers on hand. The physical inventory must be documented on the "Manual Voucher Inventory Log" and labeled "Physical Inventory Conducted and Verified by." Two staff members must initial and date the physical inventory.

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When discrepancies are discovered during a manual voucher inventory, they must be reported to the District Nutrition Services Director. Manual Voucher Inventory logs must be retained for three (3) years plus the current Federal Fiscal Year. Inventories must be completed in black or blue ink.

F. Issuance of Manual Vouchers
Manual vouchers must be issued in complete sets, in consecutive order. When preparing manual vouchers, all items must be printed clearly and legibly, using a black or blue ink ballpoint pen. If an error is made on a voucher, void the voucher and issue a blank manual voucher.
The pickup code is generally the same day as the day on which vouchers are issued. The dates on the second and third set of vouchers must correspond to the pick-up code of the first set of vouchers.
Pre-printed standard/ blank manual vouchers must include the following information: 1. The participant's WIC ID number, including self-check and
participant code. 2. Participant's name (last, first). 3. First Day to Use (MMDDYY). 4. Last Day to Use (MMDDYY), which is thirty (30) days from the
"First Day to Use." 5. Vendor must deposit by (MMDDYY) which is sixty (60) days
from the "First Day to Use." 6. Food Package Code and Voucher Code. If blank manual
vouchers are issued to replace damaged computer printed vouchers, the Food Package Code and Voucher Code from the damaged VPOD vouchers must be written on the manual voucher to retain the original information. On a blank manual voucher, the following additional information must be completed, Food Prescription Data blocks. Enter quantities for appropriate foods; enter an "X" in all unassigned blocks.

G. Distribution of Manual Voucher Copies (Only when Handwriting Vouchers)

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1. The red copy must be counted in numerical order, and mailed to the ADP Contractor using a Batch Control Form (See Attachment FD-11). Do not separate or fold the red copies. DO NOT BATCH VOUCHER COPIES WITH TADs. They may be mailed together, but must be batched separately. When sending via Express Mail, do not use a Post Office Box. The clinic address must be used for this process.
2. When a batch is mailed to the ADP Contractor, the black copy of the Manual Vouchers must be retained by the clinic and attached to a copy of the Batch Control Form, creating a Batch Control Module (BCM). BCM's must remain intact until they are reconciled.
Upon receipt of a manual voucher BCM, the ADP Contractor will send an acknowledgement receipt to the clinic on a monthly basis (with a TAD shipment).
If there are discrepancies, the ADP Contractor will send the clinic a "Batch Control Exception Report "(See Attachment FD-12), describing the discrepancy. Discrepancies should be resolved by recounting vouchers, and contacting the ADP Contractor to resolve count differences by WIC ID if necessary.
When the signed Batch Control Form is returned to the clinic, the copy of the Batch Control Form may be discarded. Voucher copies must be organized by type and stored neatly in serial number order. It is recommended that voucher copies be stored in binding materials such as vinyl lined binders, post binders, or expanding file folders in order to maintain them.
Voucher copies must be retained for three (3) years plus the current Federal Fiscal Year.

H. Voided Manual Vouchers
Vouchers marked VOID must be returned to the Contract Bank. Package the vouchers securely to prevent breakage and ensure that they arrive at the Contract Bank by noon of the fifth (5th) workday of the following month.
Voided Manual Vouchers Manual vouchers, blank vouchers, or preprinted vouchers must be voided if:
x the participant's name is misspelled;

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x any of the participant information is entered incorrectly; x damage during issuance; x a voucher(s) is returned unused by participant; x there is a food package change.
1. Voided Manual/ Vouchers That Were Reported to the ADP Contractor as Issued. The system contains an issuance record that must be voided. To accomplish this, the clinic must return the original voucher (s), if possible, to the contract bank stamped "VOID." The ADP Contractor will input this voided voucher information into the system to void the issuance record. If the original is not available, the Lost/Stolen/ Destroyed Voided Form must be used to report the void to the ADP Contractor.
2. Voided Manual/ Vouchers That Were Not Reported to the ADP Contractor as Issued. These voids are due to errors made while completing the voucher, which prevent the voucher from being issued. All three (3) manual voucher copies must be marked "VOID". Use a Batch Control Form and return the original and the second copy to the ADP Contractor. Please refer to Section FD-V.G. for information on batching manual voucher copies.
Although there are no issuance records on these vouchers, the ADP Contractor will input this voided information into the system to identify the disposition of the vouchers. All voided and destroyed vouchers must be reported to the ADP Contractor's Bank. Do not send out- of- date vouchers back to the bank, (only those vouchers that are voided due to package changes, formula changes, etc). The ADP Contractor will provide addressed envelopes or labels to be used when returning vouchers.

VI. VPOD PROCEDURES
A. General
Vouchers printed on demand (VPOD) are generated on site by the clinic's automated system for each participant on the WIC Program. The receipt generated as part of the printing process becomes the voucher register. When serial numbers are received from ADP contractor, each clinic must log all numbers on the VPOD Inventory Log and in the computer the same day that they are received but no more than three (3) days after receipt. The confirmation notice must be signed and dated and a copy sent to the district office to be kept on file. The confirmation notice must also be kept on file in the clinics in the same manner as the packing list. The
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retention period is also the same.

B. Issuing VPOD Vouchers
The following procedures must be followed when issuing VPOD Vouchers:
1. Identification - Verify the identity of the person picking up the vouchers.
2. Issuance - Before vouchers are printed, the clerk must check the client's WIC History to determine if the participant is in a valid certification period, has a nutrition education appointment, or any other follow-up appointments; that the food package code is correct and that the correct number of vouchers will be printed.
3. The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name of the participant will be compared to the participant's name on the WIC ID card and as it appears on the vouchers.
4. The client must sign the receipt before receiving the VPOD vouchers. Vouchers must not be issued until after the participant/proxy signs the receipt.

5. The receipt must be filed immediately after issuing the vouchers. Receipts must be filed in numerical order whenever possible.
C. Voucher Reconciliation
At the end of each day, the clinic staff must print a Daily Activity Report that includes:
1. Voucher numbers 2. Participant's name 3. Issue date 4. Initials of issuing clerk 5. Status of voucher (Issued or Voided)

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All receipts must be reconciled with the Daily Activity Report. The receipts must be filed in numerical order. Each clinic must maintain a file for the activity reports and keep it in the clinic. If vouchers are voided, they must be stamped "VOID" before filing them with the receipts. Clinic staff must staple or paperclip the voided vouchers to the back of the receipt. If the voucher does not print or the receipt is lost, use a blank voucher receipt to write those numbers, the date, the participant's name, the participants WIC ID number and the clerk's initials on the receipt. The Activity Report must be signed and dated to verify reconciliation each day.
D. VPOD Inventory Log Sheets
The VPOD log sheet must be completed daily or at a minimum weekly (only for those clinics who are open less than two days a week: all others must complete the log sheet daily). The log is used to keep track of the voucher numbers issued, voided or not printed. Always record the voucher numbers received from the ADP contractor on the log sheet. The top of the log sheet must reflect the packing list beginning and ending number for the series of vouchers being used. Separate log sheets can be used for each batch, but they must be kept in the inventory logbook. The confirmation notice of numbers sent will take the place of the voucherpacking list and should be maintained in the same manner. All columns of the log sheet must be completed accurately, legibly, and initialed by a responsible staff member. The bottom of the VPOD log must be completed with the remaining stock and clerk initials.
E. Corrective Actions for VPOD
1. Any missing receipt 2. Incomplete log sheets 3. More than one percent "fail to sign" on receipts 4. Vouchers issued during an invalid certification period 5. Any missing daily activity reports 6. Any vouchers filed with receipts that do not have void stamped
or written on them 7. Voucher printing problems that are not documented properly 8. Voucher numbers that did not print, and are not voided in the
computer 9. Missing participant signatures.

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VII. MAILING/DELIVERY OF WIC VOUCHERS
A. Conditions for Mailing/Delivering Vouchers
1. Vouchers may be mailed or otherwise delivered to participants on an individual hardship basis or, in special circumstances, may be mailed in mass. If vouchers are mailed to a participant for hardship reasons, they will be done so on a temporary/shortterm basis. There is no standard, on-going reason to mail vouchers (i.e. permanent difficulty accessing the clinic(s).
2. Vouchers must not be mailed in the following situations: a. Participant is due for re-certification. b. Participant is due for nutrition education. c. Participant is unable to offer a current address (i.e., homeless shelter participant).
B. Acceptable Reasons for Mailing/Delivering Vouchers
1. Difficulties of the participant and his/her proxy in obtaining vouchers for reasons such as illness.
2. Imminent or recent childbirth requiring bed rest and no proxy is available.
3. Environmental crisis as a result of a tornado, hurricane, flood, snow-storm, ice storm or other natural disaster.
4. Closure of clinic due to structural damage, relocation, etc. 5. Other special circumstances approved by the Nutrition Services
Director.

NOTE: *If the Food Stamp Program has discontinued or does not routinely mail Food Stamp Coupons to a geographical location, WIC Vouchers cannot be mailed to this area.

C. Mailing/Delivery Procedures
The procedures to be followed when mailing vouchers are as follows:
1. Prior to mailing/delivering vouchers, the issuing professional must obtain approval from the District Nutrition Services Director or a designated Competent Professional Authority

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(CPA). Written approval must be maintained on file in the form of a local agency policy memorandum.
When delivering vouchers, the participant must sign a copy of the voucher receipt. Once the receipt is signed by the participant, it must be returned to the clinic to be filed.
Original copies of the receipt must not be taken from the clinic; a copy of the receipt must be taken to the participant to sign. Upon returning to the clinic, the copy must be attached to the original receipt.
2. The hardship condition and the District Nutrition Services Director approval must be documented in the participant's health record. Once the initial hardship has been resolved, the mailing or delivery of WIC Vouchers must be discontinued and the action documented.
3. Confirm valid certification.
4. Confirm the mailing address.
5. Give the participant their next appointment.
6. Each district or local agency must have a post office box as well as a return address for all vouchers mailed. The "return to sender name" on the mailing envelope must be a staff person other than the one who prepared the vouchers for mailing.
7. A staff person other than the one who prepared and mailed the vouchers must pick-up returned vouchers from the post office box; and must note on the mail roster the participant's name, identification number and sequence of voucher numbers returned in the mail and a full signature of the person documenting this information.
8. A roster must be maintained on a weekly basis by the local office noting all vouchers mailed and participant names and identification numbers. This roster should be mailed to the District Office (See Attachment FD-14).
The procedures for delivering a voucher (s) are as follows: x The VPOD vouchers and receipts (when transporting vouchers) must be copied. x The original receipt must be left in the clinic. x Once the participant signs the copied page, the copy must be attached to the original VPOD receipt. x The original VPOD receipt must have the statement "See Attachment" on the receipt.

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D. Voucher Mailing Process
x When mailing vouchers, the VPOD receipt, or voucher copy must be documented with the disposition of the vouchers.
x The WIC official must document the signature line(s) with the statement "mailed vouchers" or "delivered vouchers".
x The reason(s) for mailing, the date mailed, and the signature of the person preparing vouchers for mailing.
x Vouchers must be mailed via certified mail. x Mailed vouchers will not be replaced.
E. Returned Vouchers
When vouchers are returned by the postal service, the following steps must be followed:
1. If the voucher(s) are still valid for redemption, the local agency must attempt to contact the participant in an effort to issue. The attempt to contact must be recorded on the voucher receipt. If the local agency is unable to contact the participant, "VOID" the voucher(s) immediately, and retain them on site until the time that they are scheduled to be mailed the bank, The only exception is for manual vouchers that are returned to Data Processing. If a record of manual vouchers has been sent to the ADP Contractor, those vouchers must be voided and sent to the bank.
2. If the vouchers expired, they must be stamped "VOID". Note on the receipt, "returned by postal service" next to the corresponding voucher numbers and retain them on site until the scheduled to be mailed to the bank. Voucher(s) must be "voided" immediately and processed in accordance with the procedures described above.

VIII. PRORATED VOUCHERS
The objective of prorated vouchers is to ensure that participants receive benefits only during a valid certification period. Vouchers are issued based on the number of weeks within a valid redemption time period. A voucher is only valid for only 30 days from the date of issuance. If it is determined that a participant cannot redeem vouchers within the valid time frame, the number of vouchers issued must be prorated.

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Prorating is the issuance of partial food packages by eliminating one or more vouchers from the designated food package. Vouchers must be prorated when: (1) A participant is late picking up vouchers (procedures for voiding
vouchers must be followed as outlined in FD-IX - Late Pickup of Vouchers).
(2) Vouchers are being replaced if they are damaged or there has been a change in the prescribed food package or as a result of agency error.
(3) A participant is categorically ineligible (See FD-III.-E. - Categorically Ineligible).
Note: The procedures in Section FD-XI. A must be followed when replacing vouchers.

Number of Days Late

Women & Children

Less than 7 days late

full package

7-13 days late

Vouchers issued 3/4 package

14-20 days late

Vouchers issued 1/2 package

21-31 days late

Vouchers issued 1/4 package

Infants full package full package
(1/2) package (deduct formula vouchers only) (1/2) package (deduct formula vouchers only)

Note: Cash Value (Fruit/Vegetables cannot be prorated. It must always be issued for the full value (e.g. $6, $8 or $10).

IX. LATE PICK-UP OF VOUCHERS
Participants who are late picking up their vouchers must be issued a prorated food package based on the schedule in FD-VIII. The food package must be prorated to reflect the period of time left until the participant's next scheduled pickup date. To determine the number of days that a participant is late for pickup, the following guidelines must be followed:
1. Count calendar days, including weekends. 2. If the participant's scheduled pickup day was before the "First Day to Use"
on the vouchers, begin counting days late from the "First Day to Use" date.

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3. If the participant's scheduled pickup day was after the "First Day to Use" on the vouchers, begin counting days late from the appointment date.
The appointment date must be documented on the receipt in addition to the required pickup date.
Change pickup interval code
When a participant is late picking up vouchers, the pickup interval code must not be changed to avoid prorating vouchers. When it becomes necessary to change the pickup interval code, the code is changed to the date the vouchers are picked up, and a full set of vouchers are issued with the current date. Clinic staff are not encouraged to change pickup interval codes because of the affects doing so may have on participation.
There are two reasons when pickup codes should be changed during a valid certification period: 1. Adding a new family member 2. A change in circumstances such as a change in job or working hours that
results in a hardship on the participant.
The decision to change pickup interval code will be the responsibility of the clinic supervisor.
To change the participant's pickup interval code the clinic staff must: 1. Document the appointment date changes on the voucher receipt. 2. Complete an update TAD to change the pickup interval code and submit
to the data-processing contractor. 3. Immediately stamp or write "VOID" on the voucher immediately. 4. Give the participant an appointment for next month's pickup with the
new pickup date. 5. Document in participant's record the reason for change in pickup interval
code.

X. COORDINATION OF HEALTH SERVICES AND VOUCHER ISSUANCE
Every effort must be made to coordinate the issuance of WIC vouchers with the delivery of health services. [CFR 246.12(d); CFR 246.11(a)(1) and (2)]. Efforts must be made to provide health services so that the patients/families will not have to return more than once a month. However, vouchers may be issued for one month, if the participant/caregiver is to return for services at that time (This is the exception not the rule).
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Under no circumstances are vouchers to be withheld or denied nor are any services to be forced upon participant/caregiver [CFR 246.11(a)(2)]. Participants/caregivers have the right to refuse other health services, but we have the responsibility to frequently offer and strongly encourage the use of all available health services [CFR 246.6(b)(3)(4)(5); CFR 246.7(I)(2)(iii); CFR 246.12(s)(7) (8)].

XI. LOST, STOLEN OR DAMAGED VOUCHERS
A. Replacement of Vouchers 1. Lost or Stolen vouchers will not be replaced. 2. Damaged Vouchers - When a participant/parent/guardian/ caretaker reports that their vouchers have been damaged the following procedure may be implemented: a. If vouchers are damaged, any pieces of the vouchers that can be salvaged should be brought to clinic. Vouchers that can be identified by voucher numbers may be replaced. b. Vouchers destroyed due to fire will be replaced with a copy of the fire report.
B. Lost/Stolen/Destroyed/Voided Voucher Report
When vouchers are reported as lost, stolen, or destroyed, complete the Lost/Stolen /Destroyed/ Voided Voucher Report (See Attachment FD15) with the following items:
1. District/Unit/Clinic 2. Current Date 3. Beginning Voucher Number in Range* 4. Ending Voucher Number in Range* 5. Quantity of Vouchers in Range 6. Participant's WIC ID Number 7. Participant's Status Code 8. Participant's Last Name and Replacement Voucher Numbers in
the "Comments" block. *If a participant reports that part of a voucher package was lost/stolen/destroyed and the other portion was cashed, but cannot determine which voucher serial numbers were lost/stolen/destroyed, include all of the voucher serial numbers on the form. Note in the comment section of the Lost/Stolen Destroyed Voided Voucher Report
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that between 1-4 vouchers may have been cashed.
Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the Georgia WIC Program, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, they will be identified on the Bank Exception Report during the monthly reporting process.
The Georgia WIC Program cannot initiate "stop payments" on lost/stolen/destroyed vouchers. When fraud is suspected, the local agency should notify the Compliance Analysis Section to request assistance with an investigation. To obtain copies of suspect vouchers, the Local Agency must submit a Georgia WIC Program Voucher Investigation Log (See Attachment CA-2) to the Compliance Analysis Section. (See Section X of CA Section of the Georgia WIC Procedures Manual)
C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance
When a clinic determines that vouchers have been lost, stolen, or destroyed prior to issuance, the following procedure must be implemented: 1. Complete the Lost/Stolen/Destroyed Voided Voucher Report
(Attachment FD-19) with the following items: a. District/Unit/Clinic b. Current Date c. Beginning Voucher Number in Range d. Ending Voucher Number in Range e. Quantity of Vouchers in Range.
2. Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the Georgia WIC Program, System Information Unit, 2 Peachtree Street Atlanta, GA 30303. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, they will be identified on the Bank Exception Report during the monthly reporting process. The System Information Unit will review Lost, Stolen, or Destroyed voucher reports in conjunction with the Cumulative Unmatched Redemption (CUR) report and Bank Exception report to identify potential fraud and refer findings to the Compliance

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Analysis Section. The Compliance Analysis Section will work in conjunction with the Local Agency to investigate potential fraud, when a block of 25 or more vouchers are missing (See Section CA-X, Investigation of Missing Vouchers).

D. Change of Formula Order/Formula Purchased In Error
In the event that a formula order is changed after a participant has been issued vouchers for an original formula order, or formula was purchased in error, replacement vouchers must be issued if the original vouchers and/or incorrect formula purchased are returned. When vouchers are replaced within the same month of original issuance, the following procedures must be implemented:

Standard Formula, Special Formula
1. Participants must return unused formula to the clinic if available, and/or
2. Return unredeemed voucher(s) to the clinic for voiding. 3. Supplemental vouchers issued must equal the amount of unused
formula returned and vouchers voided for the current issuance period. Supplemental vouchers are issued on a can for can basis. 4. Document the amount, type, and disposition of formula returned on the "Formula Tracking Log" located in the Food Package section of the WIC Procedures Manual.
Hospital Based Formula If a physician changes a formula, the participant must return all unopened cans of formula to the clinic. The Clinic must then: 1. Issue supplemental vouchers equal to the amount of formula
returned in the issuance period. 2. Document the amount, type, and disposition of formula returned
to the clinic on the Voucher Receipt or on the clinic's copy of the manual voucher. 3. Document formula change and receipt of an updated written or verbal order from the physician in the participant's health record. 4. Document returned formula on the "Formula Tracking Log" located in the Food Package section of the WIC Procedures Manual. All returned formula must be accounted for when issued to another client, destroyed or returned to the

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manufacturer. The "Formula Tracking Log" will be monitored for accuracy during District Program Reviews conducted by the state.

XII. BORROWED VOUCHERS
Vouchers may be borrowed within a District from one clinic by a clinic whose current stock is depleted (See Attachment FD-15). This applies to manual vouchers only. VPOD numbers cannot be borrowed from one clinic to another.
Submitting the form in a timely manner is important. The ADP contractor must be notified of all manual voucher reassignments as soon as possible. Any borrowed voucher reassignments not received by the ADP contractor before reconciliation (usually around the eighth working day of the month) may result in new check issues received from clinics being rejected because the issue clinic fails to match the check issue master file. Accordingly, any of these vouchers that were cashed would result in unmatched redemption the first month and would be listed on the Cumulative Unmatched Redemptions Report if not corrected by the second month.
Those borrowed voucher reassignments that fail the required edits will also be subject to the unmatched redemption process described in the previous paragraph. If a borrowed voucher reassignment does fail the edits, the districts will be contacted to correct the discrepancy for the next reconciliation. The ADP contractor will accept the new Borrowed Voucher Report input form from the districts, edit the required fields for validity, and reassign clinic numbers on the check issue master file on a monthly basis before reconciliation.

XIII. CRITICAL ERRORS
If a TAD or ETAD is submitted to the ADP Contractor with a critical error, the system rejects the file and does not update the client master file. This can cause voucher issued to that participant will show up on the Unmatched Redemption Report followed the next month by the Cumulative Unmatched Redemption (CUR) report.. Clinic staff must correct the error and re-submit the TAD or ETAD immediately. Failure to correct critical errors and unmatched redemptions may result in loss of funding to the district.
Clinic staff are encouraged to review critical error reports and batch reception reports in GWISnet daily and resubmit a corrected TAD transaction or voucher issuance record as appropriate.

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XIV. CUMULATIVE UNMATCHED REDEMPTION REPORT (CUR)

A. Introduction

The Cumulative Unmatched Redemption (CUR) Report identifies redeemed VPOD and manual vouchers that have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report monthly. The vouchers must be reconciled with the ADP contractor or a manual reconciliation should be performed with the Georgia WIC Program, depending on how much time has elapsed since the voucher was redeemed. The CUR Report has two parts:

Part 1: Part 2:

A cumulative list of vouchers issued by clinics and cashed by the participant, when there is no record that the voucher was issued on the ADP Contractor's mainframe computer system (See Attachment FD-16).
A cumulative list of vouchers issued by the clinics and cashed by the participants, which have not matched to a valid WIC ID number, issue date, or participant certification record on the ADP Contractor's mainframe computer system (See Attachment FD-17).

The Local Agency may correct an unmatched redemption list that is over 30 days old. The second month the item appears, the Local Agency must manually reconcile the items described below. These manually reconciled items should not be submitted to the ADP Contractor since the items are purged from the system after they are listed the second time.

B. Procedures for Reconciliation

Cumulative Unmatched Redemptions that have not matched to an issuance record.
CUR Part 1: Attachment FD-13 provides an example of vouchers that are not matched to an issuance record.

x Column 1: Voucher Nunber. This is the serial number of the voucher in question.
x Column 2: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their 30-Day

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Month. Vouchers in this column can still be reconciled with the ADP Contractor.
x Column 3: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their Close-Out Month. Vouchers in this column have been purged from the ADP Contractor's system and can only be manually reconciled with the State Office.

To reconcile vouchers in the second column:
1. Look in the Clinic Feedback - Batch Rejection Section of GWISnet to confirm that the batch containing vouchers appearing in Column 2 had not been rejected by the ADP Contractor.
2. If the batch is not showing as having been rejected, look in the Clinic Feedback Batch Acknowledgement Section of GWISnet. If there is no acknowledgment from the ADP Contractor that the batch was received, resubmit the entire batch to the ADP Contractor.
3. If there is acknowledgement that the ADP Contractor received the batch, the vouchers may have contained an error or been processed incorrectly by the bank. (For manual vouchers, photocopy the entire set of vouchers that were issued to that participant even if all the vouchers are not listed on the report, and make the necessary corrections on the photocopy.) Correct only those voucher(s) listed in Column 1 with the ADP Contractor.
The ADP Contractor must receive corrections and resubmitted batches by the end of the month cut-off which is the seventh working day of the month following the month in which the report was received. For paper vouchers: Complete a Batch Control Form. Batch and submit to the ADP Contractor. Do not submit copies of the CUR report to the ADP Contractor and do not send copies of those vouchers to the State WIC Office.
C. Manually Reconciling CUR Part 1
Those voucher(s) listed in the second dollar amount column are too old to correct through the ADP Contractor and must be manually reconciled by the clinic.

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1. Locate a copy of the voucher(s) listed in the second dollar amount column.
2. Record the issue date only of the voucher (the actual date as it appears on the voucher) on the dotted line adjacent to the voucher number on the CUR Part 1 report, sign and date the report. If there are no vouchers appearing on the CUR Part 1 report that have to be manually reconciled, the report should still be forwarded to the GWB. The CUR Report should always be submitted to the GWB in its entirety. Do not send copies of vouchers to the Georgia WIC Program.
Cumulative Unmatched Redemptions that have not matched to a valid certification record:
Cumulative Unmatched Redemptions that have not matched to a valid certification record or valid WIC ID number:

CUR Part 2: Attachment FD-17 provides an example of a cumulative unmatched redemption that is not matched to a valid certification record or valid WIC ID number.
x Column 1: Voucher Nunber. This is the serial number of the voucher in question.
x Column 2: Issue Date. Date on which the voucher was printed. Usually coincides with the first day to use.
x Column 3, 4, 5: WIC ID. Col 3: Family WIC ID number, Col 4: Check digit, Col 5: Participant number.
x Column 6: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their 30Day Month. Vouchers in this column can still be reconciled with the ADP Contractor.
x Column 7: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their CloseOut Month. Vouchers in this column have been purged from the ADP Contractor's system and can only be manually reconciled with the State Office.
x Column 8: Reconciliations. Provides space for clinic staff to indicate how the voucher was reconciled. This is only for vouchers appearing in the Close-Out Month.
x Column 9: Reason: Indicates the reason that the vouchers appeared on the CUR Part 2. This information is provided by the ADP Contractor.

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x Column 10: Total. Provides a count of the total number of vouchers (30-Day + Close-Out) that appear on the CUR Part 2 report.

To reconcile vouchers in the sixth column:
1. Refer to the Reason in Column 9. This will indicate why the voucher appeared on the report and will give the clinic staff a starting point for research.
2. If the reason for appearing on the report is "Issued After Term" check the Clinic Feedback Batch Acknowledgement Section in GWISnet. If the batch containing the voucher(s) in question does not appear, go to the Batch Reject Section. If the batch is not located in either section re-submit the batch to the ADP Contractor.
3. If the batch appears in the rejected section look to determine the reason. If possible, correct the error and re-submit the batch.
4. In the case where the batch appears in the Acknowledgement Section review the critical errors for the time that the batch was sent. If the client's ETAD transaction appears, correct the error and re-submit only that transaction. Re-submitting the entire batch will result in numerous critical errors.
5. Verify that the issue date and/or the ID number are correct as it appears on the voucher and the CUR report. If both or either the issue date or the ID number is incorrect, complete only the appropriate column of the CUR Part 2 Correction Form with the correct issue date and/or ID number for the entire set of vouchers listed. Mail the top copy of the form to the ADP Contractor. Retain the bottom copy for your files. Do not submit a copy of the CUR Part 2 Correction Form to the State Office.
6. When the issue date and the ID number on the voucher(s) and the CUR Part 2 report are correct:
x Verify that the participant was in a valid certification period on the date the voucher was issuance. If the participant was not within a valid certification period when the voucher was issued, there is no correction to be made and the voucher will appear on the next CUR report. Briefly document on the dotted line adjacent to the voucher number on the CUR report why the

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vouchers were issued outside of a valid certification period.
x If the vouchers were issued within a valid certification period, verify whether the TAD transaction creating the valid certification was batched and submitted to the ADP Contractor (See above). If there is no batch acknowledgment, resubmit the entire batch to the ADP Contractor.
x If the TAD was submitted to the ADP Contractor, it may have contained a critical error. Review critical error reports and resubmit a corrected TAD transaction as appropriate.
x Correct only those voucher(s) listed in the 30-Day column (Column 4) on the report with the ADP Contractor. The ADP Contractor must receive corrections and resubmitted batches by the end of the month cut-off which is the seventh working day of the month following the month in which the report was received.

D.

Manually Reconciling CUR Part 2

Vouchers listed in the seventh column have expired and cannot be corrected through the ADP Contractor. These vouchers must be manually reconciled to the State Office.

x Locate the copy of the voucher receipt and check the ID number, name, and issue date. If the issuance date or the ID number on the receipt or the CUR Part 2 report is erroneous, record only the corrected information on the dotted line adjacent to the voucher number on the CUR Part 2 report.

x If the issuance date and the ID number on the CUR Part 2 are correct, record briefly the reason the voucher(s) were issued.
x The first voucher of a set of vouchers issued to a participant appearing in the seventh column must be manually reconciled with the State Office. (See Attachment FD-17)
x Sign and date the completed report and submit to the Georgia WIC Program. If there are no vouchers on the

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report to be manually reconciled, the CUR report should still be forwarded to the GWB in its entirety. Do not send CUR reports to the ADP Contractor.

E. Procedures for Both Reports
1. Clinics must submit the completed reports to the District Office and the District Office will submit all the reports in one batch to the Georgia WIC Program by the 22nd of the month following the report's run date month (i.e., if the run date is 2/18/08, the manually reconciled CUR report is due to the Georgia WIC Program by 3/22/08). Clinics must not submit their reports directly to the State Office.
2. If you are unable to locate a copy of a specific voucher or vouchers, send a memo to the Georgia WIC Program requesting a copy of the voucher(s). Please include the redemption month along with the voucher number(s).

XV. UNMATCHED REDEMPTION REPORT
In order to reduce the cases of unmatched vouchers, the Georgia WIC Program began issuing the Unmatched Redemption Report. This report acts as an issue month CUR.
Vouchers appearing without a participant's name have been cashed but no issue record has been received. These are potential CUR Part 1 vouchers. Vouchers with unindentifying client information are potential CUR Part 2.
The Unmatched Redemption Report must be corrected monthly in the same manner as the CUR Reports.
XVI. RECONCILIATION OF WIC REPORTS AND DAILY PROGRAM OPERATIONS
WIC Coordinators and Clinic Managers are responsible for ensuring daily verification, daily reconciliation of WIC reports and daily program operations for accuracy. Districts must immediately report discrepancies to the Georgia WIC Program Systems Information Section. Reconciliation includes, but is not limited to, conducting the following daily and monthly verifications.

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A. Daily Verifications
1. Verify vouchers issued. 2. Match numbers on the computer with vouchers issued. 3. Ensure all vouchers contain required voucher numbers. 4. Ensure that numbers received are properly entered into the system. 5. Ensure that vouchers do not skip numbers. If a number(s) is
skipped, document the number on activity log and in the VOIDED section of the inventory log. 6. Verify that duplicate numbers have not been issued to the same participant. 7. Batching must be done daily or on any day when vouchers have been issued. 8. Review and correct critical errors.
B. Monthly Verifications
1. Ensure that all vouchers are appropriately issued and/or voided. "Did not print" is not an acceptable voucher status.
2. Review Unmatched and CUR reports and reasons indicated. 3. Assure voucher redemption report are verified and resubmitted in
the required time frame.
Clinic managers should report all discrepancies to the District Nutrition Services Director immediately. In addition, it is the responsibility of the WIC Coordinator to conduct periodic self-reviews as well as review any discrepancies or problems reported by the clinic manger.

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GA WIC 2010 PROCEDURES MANUAL

Attachment FD-1

PREPRINTED STANDARD MANUAL VOUCHER

FD-35

GA WIC 2010 PROCEDURES MANUAL BLANK MANUAL VOUCHER

Attachment FD-2

FD-36

GA WIC 2010 PROCEDURES MAMUAL

Attachment FD-3

VOUCHER PRINTED ON DEMAND (VPOD VOUCHER)

FD-37

GA WIC 2010 PROCEDURES MANUAL
WIC FMNP check
UNITED COMMUNITY BANK 64-1968

Attachment FD-4
XXXXXXX

FD-38

GA WIC 2010 PROCEDURES MANUAL

Attachment FD-5

Senior FMNP Check
GEORGIA DEPARTMENT OF HUMAN RESOURCES SENIOR FMNP MARIETTA, GA 611 UNITED COMMUNITY BANK 64-1968

XXXXXXX

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Attachment FD-8

STANDARD MANUAL___________ CLINIC___________

BALANCE BROUGHT FORWARD_________________

DATE BEGINNING NO. ENDING NO. NO.RECEIVED NO. ISSUED NO. VOID NO. ON HAND INITIALS INITIALS

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GA WIC 2010 PROCEDURES MANUAL

Attachment FD-10

BATCH CONTROL FORM

GEORGIA WIC PROGRAM

DISTRICT/UNIT

CLINIC

BATCH CONTROL FORM

DATE

NUMBER

/ /

/ /

INSTRUCTIONS
CSC COVANSYS INPUT SECTION COMMENTS:

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUED/VOIDED MANUAL VOUCHERS.
2. DO NOT BATCH TADS WITH MANUAL VOUCHERS
3. SUBMIT THIS FORM WITH THE TADS AND ISSUED MANUAL VOUCHERS TO:
CSC COVANSYS P.O. BOX 2507 GREENWOOD, IN 46142
SUBMIT THIS FORM WITH THE VOIDED MANUAL VOUCHERS TO:
CSC COVANSYS 1000 COBB PLACE BLVD BUILDING 100, SUITE 190 KENNESAW, GEORGIA 30144 ATTN: JOHN REYNOLDS

4. RETAIN A COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS, ISSUED MANUAL VOUCHERS OR VOIDED MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT
TURNAROUND

NUMBER IN BATCH

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

DATE SENT BY DISTRICT/UNIT DATE RECEIVED AT CSC COVANSYS DATE ENTERED AT CSC COVANSYS

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GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

TABLE OF CONTENTS Page
I. Introduction ............................................................................................................... CA-1 II. Monitoring ................................................................................................................. CA-1 III. Participant Abuse...................................................................................................... CA-2
A. Dual Participation ......................................................................................... CA-2 B. Duplicate Participation Verification Form ................................................ CA-4 C. Participant Abuses and Sanctions .............................................................. CA-4 IV. Procedures for Repayment of WIC Funds ........................................................... CA-8 V. Guidelines for Investigating Employee Abuse.................................................... CA-9 VI. Procedures to Request an Employee Investigation............................................ CA-10 VII. Vendor Compliance Investigation........................................................................ CA-11 VIII. Compliance Investigation Food Purchases ......................................................... CA-11 IX. Disqualified Vendor/Participant Access............................................................. CA-12 X. Investigation of Missing Vouchers/Verification of Certification Cards (VOC) ..................................................................................... CA-12 A. Manual Voucher Inventory ....................................................................... CA-13 B. Georgia WIC Voucher Investigation Log ................................................ CA-13 C. Stop Payment of WIC Vouchers ............................................................... CA-14 XI. Security of Issuance Materials............................................................................... CA-14 A. Georgia WIC Program Stamps.................................................................. CA-14 B. VOC Cards .................................................................................................. CA-14 C. Georgia WIC ID Cards ............................................................................... CA-14 XII. Voucher Issuance Security..................................................................................... CA-15 A. WIC Vouchers.............................................................................................. CA-15 B. Voucher Security ......................................................................................... CA-15 C. Voucher Storage .......................................................................................... CA-16 D. Voucher Printing on Demand (VPOD) ................................................... CA-16 E. Transporting Georgia WIC Vouchers ...................................................... CA-16

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

Attachments:
CA-1 Closeout Reconciliation Report............................................................................. CA-17 CA-2 Georgia WIC Voucher Investigation Log ............................................................ CA-18 CA-3 Dual Participation Sample Warning Letter......................................................... CA-19 CA-4 Participant Sample Warning Letter...................................................................... CA-20 CA-5 Request for Investigation ....................................................................................... CA-21 CA-6 Georgia WIC Transaction Report ......................................................................... CA-22 CA-7 Participant Access Verification Form................................................................... CA-23 CA-8 Georgia WIC Program Vendor Donation List .................................................... CA-24 CA-9 Notification Summary of Missing Vouchers/VOC Cards................................ CA-25 CA-10 Duplicate Participation Verification Form .......................................................... CA-26 CA-11 Participation Repayment Sample Letter.............................................................. CA-27 CA-12 Participant Repayment Schedule Sample Letter ................................................ CA-28 CA-13 Dual Participation Report Investigation Form ................................................... CA-29 CA-14 Georgia WIC Program Abuse Claims Payment Report.................................... CA-30

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

I. INTRODUCTION
The Compliance Analysis Section (CAS) assesses programmatic compliance for approximately 1800 retail grocery stores (Georgia WIC Vendors). CAS performs covert investigations to deter potential abuse and to ensure the appropriate delivery of Georgia WIC approved food items.
The section is responsible for the investigation of vouchers reported missing or stolen from WIC clinics. Clinic investigations are performed in conjunction with the Office of Investigative Services.
The Section also investigates participant and employee fraud associated with Georgia WIC clinics. Report analysis is performed to determine dual participation and system related fraud and abuse.

II. MONITORING
Clinic reviews are conducted to assess the security of WIC vouchers and voucher issuance materials in WIC clinics during issuance, staff breaks, and at the close of business.
1. Annually, the local Nutrition Services Directors or designee will visit each clinic for the purpose of reviewing clinical procedures, as outlined in the Self Review Monitoring Tool.
2. If the review of vouchers/voucher-related materials causes suspicion, and the Nutrition Services Director determines that an investigation is needed, the Nutrition Services Director shall notify the Georgia WIC Program and proceed with the investigation. The Georgia WIC Program may notify USDA-Food and Nutrition Services (FNS) of the impending investigation and keep them informed of case progress on a periodic basis or as requested.
3. The Closeout Reconciliation Report (See Attachment CA-1) is generated for the local agency and indicates the final disposition of all computerprinted vouchers. This report should be used to monitor the disposition of any vouchers that have a questionable status (i.e., voids, fail to sign, etc). If findings lead to suspicion and the Nutrition Services Director determines an investigation is needed, the Nutrition Services Director shall notify the Georgia WIC Program and proceed with the investigation.
4. The Georgia WIC Program shall retrieve voucher copies when the Nutrition Services Director determines the need during an investigation. These vouchers will be reviewed by the Georgia WIC Program for

CA-1

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

compliance prior to being forwarded to the Local Agency. A Georgia WIC Voucher Investigation Log should be used when requesting voucher copies from the Georgia WIC Program (See Attachment CA-2).
5. Investigations may include but are not limited to review of the voucher inventory, cashed vouchers, certification records, employee/relative participation in the Georgia WIC Program, and if necessary, contacting WIC participants to verify that vouchers were picked up.
6. Investigative/monitoring clinical reviews will be conducted in conjunction with the monitoring team, and when deemed necessary.

III. PARTICIPANT ABUSE
Report Analysis: The section conducts monthly reviews of Dual Participation Reports that may lead to the investigation of program participants. Financial penalties may be assessed to participants found guilty of violations. Other system reports, including system-generated reports, manual reports, and ad hoc reports are also analyzed.
A. Dual Participation
Dual participation occurs when individuals concurrently participate in one or more WIC clinics. The Georgia WIC Program's automated data system generates a monthly "Dual Participation Report." This report specifies possible duplicate enrollment in alphabetic sequence, (See Georgia WIC Reports on GWIS for details). The report data is compiled into a composite state report as well as a report for each local agency.
The ADP Contractor downloads a Composite Dual Participation Report monthly to the Georgia WIC Program and to each local agency. The local agency must investigate and reconcile each possible dual enrollment. The reconciled report must be submitted to the Georgia WIC Program within fifteen (15) days from the run date of the report. The report must include the status of the participant (active or terminated), last voucher pickup date, participant's mother, guardian or caretaker's name, and termination date if applicable. The Dual Participation Report must be signed and dated by the person completing the report. The Dual Participation Report Investigation Form must be used (See Attachment CA-13) and attached to the Dual Participation Report. Upon receipt of these completed reports, the Georgia WIC Program will eliminate obvious false duplicates by: 1. Transferring all actions taken by local agencies onto the
Statewide or composite report.

CA-2

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

2. Notifying local agencies that have participants whose enrollment has not been reconciled.
The local agency must conduct further investigation until all alleged dual participation is resolved.
The following are examples of possible dual participation situations and the procedures for reconciliation: 1. Participant Enrolled in the Same Local Agency at the Same Clinic
Site.
Investigate to determine if there is any difference in the spelling of the first name. If so, twins may be enrolled. If the first names are spelled exactly the same, then investigate clinical records to determine if it is the same participant or different participants. Document dual participation information obtained and the final action taken on each case in the participant's health and issuance records.
The current TAD field code #54 allows the system to identify multiple births. This should reduce, if not eliminate, twins from appearing on the dual participation report.
2. Participant Enrolled in the Same Local Agency at Different Clinic Sites.
Investigate to determine if the participant has received vouchers at both clinic sites. If not, it is possible that two turnaround documents (TADs) were inadvertently printed. The TAD that is incorrect (based on the clinic site the participant is attending) must be deleted. If the participant has picked up vouchers in both sites for the same month, a possible case of participant abuse exists. Refer to the "Participant Abuses and Sanctions" section below for procedures regarding this type of abuse. Documentation must be forwarded to the Georgia WIC Program as a part of the Dual Participation Report, and a copy of the same documentation must be placed in the participant's clinic file.
3. Participant Enrolled in Different Local Agencies Contact the other local agency and together investigate the possibility of dual participation. Each local agency should

CA-3

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

review health and issuance records. If the participant has moved, the local agency from which the participant moved must terminate the participant. If dual participation and/or intentional fraud is involved refer to the section on Participant Abuses and Sanctions for procedures regarding how to proceed with this type of abuse. Documentation of dual participation information and final action on each case must become a part of the participant's clinic file.
B. Duplicate Participation Verification Form
The Duplicate Participation Verification Form (See Attachment CA-10) is printed and distributed by the ADP Contractor. The local agencies will use this form to notify the ADP contractor to terminate a dual participant from the specified clinic.
The Duplicate Participation Verification Form must be completed when dual participation has been verified by the local agency. The form should be mailed to the ADP contractor as soon as dual participation has been verified. Route the form as follows: white copy-ADP Contractor, yellow copy-Georgia WIC Program, pink copy-District Office, gold copy-WIC Clinic.
C. Participant Abuses and Sanctions
The Georgia WIC Program may assess claims and penalties against a participant when the participant has abused program guidelines. All actions taken as a result of participant abuse must be documented in the participant's health record. This includes, but is not limited to, verbal warnings, written warnings, suspensions, and terminations.
In all cases of suspension or termination from the program, the participant must receive notice of suspension or termination. The Notice of Termination /Ineligibility/Waiting Form must be completed. The specific program abuse must be entered in the appropriate space. A copy of the form must be filed in the participant's health record.
Exceptions
Before disqualifying a participant from the program, the local agency may warn a participant (See Attachment CA-3) or decide not to impose a mandatory sanction if:

CA-4

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

1. Within 30 days of receipt of the letter demanding repayment, full restitution is made by the participant.
2. A repayment schedule is agreed upon. 3. Or in the case of an infant, child, or participant under the age of
18, the state/local agency approves the designation of a proxy.
Terminations
The local agency may permit a participant to reapply for the program before the end of a mandatory disqualification period if: 1. Full restitution is made. 2. Repayment schedule is agreed upon. 3. In the case of a participant who is an infant, child or under age
18, the State or local agency approves the designation of a proxy.
At the time of disqualification, the local agency must advise the participant of the procedure to follow to obtain a fair hearing (See Rights and Obligations Fair Hearing Section).
When appropriate, the local agency must refer participants who violate program requirements to Federal, State, or local authorities for prosecution under applicable statues.
1. ABUSE: Participating in more than one Georgia WIC Program simultaneously (dual participation). SANCTION: When dual participation is discovered, the participant must be removed from the program. The participant must be given a termination notice in writing that simultaneous participation in more than one (1) program is in violation of WIC regulations (See Abuse #2 for further sanction procedures). The participant will be disqualified from participation for one (1) year.
2. ABUSE: Intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts. This includes, but is not limited to, information concerning income, family size, personal ID, residence, diet intake, and medical history. SANCTION: The participant may be required to pay the Georgia WIC Program, in cash, the value of benefits improperly issued to them. The "value of benefits" is the dollar amount of WIC vouchers which were issued and cashed or the cost to the

CA-5

GA WIC 2010 PROCEDURES MANUAL

Compliance Analysis

Georgia WIC Program of the special formula provided through the Office of Nutrition. Any benefits received through fraudulent information will be pursued administratively.
When it is suspected that intentional misrepresentation may have occurred, the local agency is to notify the Georgia WIC Program of such occurrence. Based upon the information received from the local agency, the Georgia WIC Program will make a determination as to whether the misrepresentation or falsification was intentional. All facts must be documented in writing.
Prior to the GeorgiaWIC Program determination, the local agency shall provide the Georgia WIC Program, in writing, with the following information: a. Copy of the front and back of the WIC Assessment/
Certification Form signed by the participant or authorized representative. b. The serial number of all WIC vouchers, manual and computer, issued to the participant or authorized representative within the certification period. c. A written summary specifying what information was supplied by the participant or authorized representative, what the actual information is suspected to be, and a statement as to whether it is suspected that the falsification was intentional.
Based on the information received from the local agency, the Georgia WIC Program will make a determination as to whether falsification and/or intentional misrepresentation have occurred. If the misrepresentation or falsification is determined to be intentional, the Georgia WIC Program will proceed as follows: a. Secure the vouchers cashed by the participant from the
contract bank and/or WIC banking. b. Determine the total value of the cashed vouchers. c. Make a recommendation that the local agency take the
following actions within seven (7) days: (1) Notify the participant of the findings. If the investigation
findings determine the participant is eligible for program benefits, a sanction will be imposed for a disqualification period of one (1) year. The participant will be notified, by certified mail, of his/her disqualification and right to a fair hearing. (2) If the investigation findings establish that the participant is ineligible for program benefits, the participant will be

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GA WIC 2010 PROCEDURES MANUAL

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immediately terminated from the program. The participant will be sent, by certified mail, a Notice of Termination Form, which includes notification of their right to a fair hearing. (3) If the total value of benefits issued is less than $100, it will be documented in the participant's health record. No recovery action will be initiated the first time, however, (1) and (2) above still apply. If the same offense occurs a second time, steps will be taken to recover all of the misappropriated benefits. (4) If the total value of benefits issued is $100 or more, the local agency will notify the participant of the dollar value of WIC vouchers cashed and request repayment (See Attachment CA-11 and CA-12 for Sample Letters). In no instance will repayment arrangements be extended beyond ninety (90) days from the date notification is provided to the participant. (5) The State will maintain all records of participant fraud abuse or fraud regardless of dollar amount.
3. ABUSE: Sale or exchange of vouchers or WIC food items with other individuals or parties.
SANCTION: When proof of abuse has been established, the participant may receive a first offense warning in writing (See Attachment CA-4) Subsequent abuse will result in disqualification from the program for a period not to exceed one (1) year. The participant must be notified of his/her right to a fair hearing (See RO-Section Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2C4) will be implemented.
4. ABUSE: Receiving cash for vouchers from food vendors, or credit toward purchase of unauthorized food or other items of value in place of approved WIC foods.
SANCTION: When proof of abuse has been established, the participant will be suspended from the program for a period not to exceed one (1) year. The participant must be notified of his/her right to a fair hearing (See RO-Section-Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2C4) will be implemented.

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The Georgia WIC Program must be notified if this abuse is occurring in order for appropriate action to be taken with the vendor.
5. ABUSE: Speaking to clinic staff, vendor personnel, and/or other WIC participants in an obnoxious, threatening, obscene or derogatory manner. SANCTION: The participant should be warned, in writing, of the inappropriate behavior and the action that will be taken if the problem continues. If the problem does continue, the participant may be suspended from the program for a period not to exceed one (1) year.
6. ABUSE: Physically hurting, pushing, or inappropriate physical handling of clinic staff, vendor personnel or property, and/or other WIC participants in the clinic/store. SANCTION: If local agency staff determines that the abuse is extensive and/or detrimental to clinic staff, the local agency may contact the local authorities, i.e. police, and may also suspend the participant(s) from the program for a period not to exceed one (1) year

IV. PROCEDURES FOR REPAYMENT OF WIC FUNDS
A. Repayments will be submitted to the local agency and must be in the form of a cashier's check or money order payable to: DCH/Georgia WIC Program. 1. The local agency will immediately forward all repayments received to the Georgia WIC Program for processing.
2. If total payment is not made within the ninety (90) day timeframe, the local agency will notify the Georgia WIC Program, which will in turn proceed with recovery actions prescribed under the Georgia Statute. "When appropriate, the Georgia WIC Program must refer participants who violate program requirements to Federal, State or Local authorities for prosecution under applicable statutes[(7 c FR246.12(u) (5)].
3. The Georgia WIC Program shall continue collection procedures until it determines it is no longer cost effective. The Georgia WIC

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GA WIC 2010 PROCEDURES MANUAL

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Program Abuse Claims Payment Report will be used to document repayment of funds (See Attachment CA-14).
4. The Georgia WIC Program will maintain records of all participant abuse regardless of dollar amount.
B. Collection of claims for repayment of benefits is suspended if an appeal for a fair hearing is requested. 1. The suspension remains in effect until a fair hearing decision is rendered.
2. If a fair hearing decision at the local level is rendered in favor of the local agency, efforts to collect repayment must be resumed.
3. Repayment efforts must be resumed even if the local level decision is being appealed to the next level.

V. GUIDELINES FOR INVESTIGATING EMPLOYEE ABUSE
Department of Community Health Policy 1201 Standard Code of Conduct states that any employee that violates WIC policies and procedures will be terminated required to pay back funds to the agency, and face possible prosecution.
When intentional employee abuse is found, it may be considered employee misconduct. Suspected intentional abuse shall be investigated by the local agency with assistance from the Georgia WIC Program, and may require a Department of Community Health Office of Investigative Services (DCH-OIS) investigation.
Intentional abuse is a deliberate effort to defraud the Georgia WIC program (example: illegally taking WIC vouchers; giving false/misleading information in order to become certified for WIC, etc).
A. Employees participating in the Georgia WIC Program shall have the same rights and obligations as any other WIC participant, however, employees are not allowed to issue vouchers or certify themselves or family members.
B. Employees participating in the Georgia WIC Program shall adhere to the rules and regulations for program participation and job responsibilities.

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GA WIC 2010 PROCEDURES MANUAL

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C. A DCH-OIS investigation shall be handled in conjunction with the local agency.

D. Action to be taken as a result of DCH-OIS investigation findings shall depend on local agency personnel policy and procedures concerning the employee misconduct.

E. Prosecution shall be processed through the District Attorney's Office. The local agency requesting an order of prosecution, shall notify the Georgia WIC Program and the Georgia WIC Program shall notify USDA-FNS.

F. The Georgia WIC Program recommends that any employee found to be abusing the Georgia WIC Program should be removed promptly from issuing or processing WIC vouchers, without reappointment rights.
G. The Georgia WIC Program shall inform USDA of any investigations of WIC related employee fraud.
H. The Georgia WIC Program will maintain all records of employee abuse regardless of dollar amount.

VI. PROCEDURES TO REQUEST AN EMPLOYEE INVESTIGATION
A. The District Health Director shall forward a letter requesting an investigation directly to the DCH-OIS and a copy of the letter must be forwarded to the Division of Public Health Director's Office and the Georgia WIC Program.
B. Contract agencies requesting an employee investigation shall submit their letter to the Division of Public Health Director's Office and a copy to the Georgia WIC Program. The Director's Office shall then forward the request for investigation along with a cover letter to DCH-OIS.
C. DCH-OIS investigation results will be forwarded to the office, which initiates the request. The initiating agency shall submit the results to the Nutrition Services Director, Program Manager, Health Director and a copy to the Georgia WIC Program.

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VII. VENDOR COMPLIANCE INVESTIGATION
Compliance investigations will be initiated by the Georgia WIC Program.
Investigations will occur at stores that have been identified as "High Risk" by the Georgia WIC Program through the use of ADP system reports, complaints, the Request for Investigation Forms received from the districts and random selection.
A Request for Investigation Form (See Attachment CA-5) should be completed on any store the local agency has reason to believe is violating WIC procedures. A copy of the Request for Investigation Form should be mailed as soon as possible to the Georgia WIC Program for action. (See Complaints Against Vendors, in the Vendor Procedures section of this manual).
Vouchers to be used by the Georgia WIC Program in compliance investigations will be generated by the Georgia WIC Program. Investigations will be documented using a WIC Transaction Report (WTR) (See Attachment CA-6).

VIII. COMPLIANCE INVESTIGATION FOOD PURCHASES
WIC foods and other food items purchased as a result of compliance investigations must be donated to non-profit organizations. Such non-profit organizations include but are not limited to:
1. City and County Fire Department(s) 2. City and County Police Department(s) 3. Retirement Homes 4. Battered Women Shelters 5. Church Organizations 6. Homeless Shelters 7. Salvation Army 8. Food Pantry (Bank) 9. Head Start Program 10. Boy Scouts 11. Girl Scouts
The compliance investigator must complete a Food Donation List (See Attachment CA-8) and submit it to a non-profit organization for verification. A representative of the non-profit organization must sign the donation list to confirm the receipt of

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foods and may obtain a copy of the list for their records.

IX. DISQUALIFIED VENDOR/PARTICIPANT ACCESS
If a vendor is found in violation of program policies and federal regulations following a compliance investigation(s), the vendor will be assessed sanctions for violations occurring during each investigative visit. If a vendor accumulates the maximum allowable sanctions, the store shall be disqualified from Georgia WIC Program participation (See Vendor Sanctions-Vendor Section of the Procedure Manual). In the event a vendor disqualification creates inadequate participant access for WIC participants, procedures outlined in the Vendor Handbook (inadequate participant access cases) will be implemented. Procedures and guidelines for vendor disqualification, as a result of an investigation, are found in the Vendor Handbook-Terminations/Disqualification Section.
To assess inadequate participant access in obtaining WIC foods as the result of a vendor disqualification, the Georgia WIC Program will initiate the verification process by completing the Participant Access Form (See Attachment CA-7). The purpose of the "Access Form" is: (a) to verify if a disqualified vendor's absence will create inadequate access for WIC participants; and/or (b) to verify that there is adequate participant access. Verification of inadequate participant access will be in accordance with Inadequate Participant Access Procedures as stated in the Vendor Section.

X. INVESTIGATION OF MISSING VOUCHERS/VERIFICATION OF CERTIFICATION CARDS (VOC)
Vouchers/VOC cards reported missing or stolen from WIC clinics will be investigated by local agencies in conjunction with the Compliance Analysis Section of the Georgia WIC Program. Investigating agencies may include the DCH Office of Investigative Services and the local police department. Local agencies may be subject to corrective action(s) and/or financial penalties if program regulations are violated.
When twenty-five (25) or more WIC vouchers or five (5) or more VOC Cards are missing, the Notification Summary of Missing Vouchers/VOC Cards (See Attachment CA-9) must be completed. However, if five (5) or fewer cards are reported missing again from the same clinic, state staff will make a special site visit. When vouchers/VOC cards are discovered missing, immediately notify the supervisor, Nutrition Services Director, and the Police. The assigned detective shall be given the name of either the Nutrition Services Director or their designee as

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GA WIC 2010 PROCEDURES MANUAL

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a contact person while conducting their investigation. The Nutrition Services Director/designee shall report details of investigation to the Compliance Analysis Section.
The Nutrition Services Director or designee must submit the Notification Summary to the Georgia WIC Program within three (3) working days of the discovery of missing vouchers/VOC cards. Immediately following initial contact from the local agency, the Georgia WIC Program will notify WIC vendors and instruct the contract bank to place a stop payment on the missing vouchers. For additional instructions on VOC cards, refer to the Certification Section of the Procedures Manual.
A. MANUAL VOUCHER INVENTORY
Document the serial numbers of the vouchers that are lost or stolen on the manual voucher inventory.
B. GEORGIA WIC VOUCHER INVESTIGATION LOG

1. To request WIC voucher copies, complete the Georgia WIC Voucher Investigation Log (See Attachment CA-2) with the following: a. District/Unit b. Current date c. Reason for investigation (suspected fraud, etc.) d. List voucher numbers e. Issue date (date missing if manual voucher) f. Clinic number g. Sign and date.
This form should be completed whenever any voucher copies are being requested.
2. Mail the completed Georgia WIC Investigation Log to the Georgia WIC Program, Compliance Analysis Section, along with the Lost/Stolen/Destroyed/Voided Voucher Report. The Compliance Analysis Section will follow up with the local agency immediately on reports that indicate potential fraud.
3. Upon receipt of special request voucher copies, the local agency should conduct a review to determine if potential fraud exists, and to notify the Compliance Analysis Section if further review or an investigation is required, within thirty (30) days of receipt.

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4. The local agency shall work in conjunction with the Georgia WIC Program during an investigation of missing vouchers. When a determination has been made that potential employee fraud exist, the DCH Investigative Services must be contacted (See V. and VI. of the CA Section).

C. STOP PAYMENT OF WIC VOUCHERS
The Georgia WIC Program will immediately upon notification, place a stop payment on WIC manual vouchers reported stolen from WIC clinics.

XI. SECURITY OF ISSUANCE MATERIALS
A. Georgia WIC Program Stamps 1. Georgia WIC Program stamps must be stored in a locked desk, cabinet, or closet. The key which locks the desk, cabinet, or closet must be stored in a secure location. 2. Georgia WIC Program stamps must be stored in a location separate from WIC vouchers, I.D. cards, and VOC cards.
B. VOC Cards 1. VOC cards must be stored in a locked desk, cabinet, or closet. The key that locks the desk, cabinet, or closet must be stored in a secure location. 2. VOC cards must be stored separately from the VOC card inventory.
C. Georgia WIC ID Cards 1. ID cards must be stored in a locked desk, cabinet, or closet. The key that locks the desk, cabinet or closet must be stored in a secure location. 2. ID cards must be stored separately from VOC cards, WIC vouchers, and program stamps.
Note: ID cards must not be pre-stamped for usage in the clinic.

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XII. VOUCHER ISSUANCE SECURITY
A. WIC Vouchers
WIC vouchers are food instruments (checks, coupons, etc.) that are used by a participant to obtain supplemental foods. The Georgia WIC Program and local agency have the responsibility to maintain control and provide accountability for the receipt and issuance of supplemental foods and food instruments. The Georgia WIC Program and local agency must also ensure that there is secure transportation and storage of un-issued food instruments. In the event that unused vouchers are lost or stolen as a result of failure to follow security regulations, the local agency may be issued a repayment letter for the value of the lost or stolen vouchers in question.
1. All vouchers must be stored in a locked cabinet, desk, or closet when not being issued. The key, which locks the cabinet, desk, or closet, must be stored in a secure location (change location of keys occasionally).
2. When issuing manual vouchers from a computer, the clerk must log out before leaving the workstation.
3. When more than one person is using the same terminal, each person must log out upon completion of their printing job.
4. Passwords must be changed every 90 days at a minimum. 5. When a voucher issuance employee resigns or is no longer
authorized to issue vouchers, the following procedures should be implemented: a. Within three (3) business days, delete employee's name
from the system. b. Change all passwords that the employee had access to. c. Change key to voucher security door (when applicable). d. Change location of all security keys. 6. Only authorized persons may be given access to WIC vouchers.

B. Voucher Security
Voucher stock must not be accessible to participants or other unauthorized persons. Except for the vouchers issued to the participant served, multiple vouchers must not be placed on top of the issuance counter. One of the following methods must be used to assure at least minimum security for voucher issuance station(s):

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GA WIC 2010 PROCEDURES MANUAL

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1. Service Delivery Counter, which will provide a shield between the issuance clerk and the participant;
2. Half Door may be used in a small clinic with only one clerk; 3. Vouchers must be kept three (3) feet out of the reach of the
participants, or there must be a physical barrier between the vouchers and the participant.
C. Voucher Storage
At a minimum, when clinics are closed, districts must utilize at least one of the following voucher storage methods: 1. If vouchers are locked in a standard cabinet, the cabinet must be
in a locked room, within a locked building; 2. A locked cabinet in a locked building with an alarm system; 3. A fire proof insulated security file cabinet with combination lock,
securely attached to the floor, in a locked building; 4. A safe securely attached to the floor in a locked building; 5. A vault in a locked building.
D. Voucher Printing on Demand (VPOD)
VPOD Printers must not be accessible to participants or other unauthorized personnel. The printers must be in a secure location and exclusively used to print VPOD vouchers.
E. Transporting Georgia WIC Vouchers
When transporting WIC vouchers, program stamps, and VOC cards, to a clinic site, they must be secured in a locked box or locked briefcase (See FD-IV., E-Transporting VPOD Vouchers.). When vouchers are being delivered to a client in a hospital setting, the vouchers must be kept in a locked box, locked clipboard or lock brief case.

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GA WIC 2010 PROCEDURES MANUAL

Attachment CA-1

D/U #:

CLOSEOUT RECONCILIATION REPORT CL #:

PAGE 20634 REPORT EWRR840G GRADY MATL & INFANT CARE

STATE OF GEORGIA WIC SYSTEM CLOSEOUT RECONCILIATION REPORT FOR THE CLOSEOUT MONTH OF JUNE 1995

WIC ID

PARTICIPANT NAME

VOUCHER REFERENCE FAMILY C P NUMBER NUMBER

25709399 55236263

999054588 2 1

LAST

FIRST

VCHR TYPE
055

REDMO AMT 10.61

26499328 48629635

697012089 2 1 -

047

12.14

26488329 26488330 26488331 25709404 25709405 25709406 25709407 25709412 25709413 25709414 25709415 25709420 25709421 25709422 25709423 26488336 26488337 26488338 26488339 26488344 26488345 26488346 26488347 26488352 26488353 25709428 25709429 25709430 25709431 25488356 26488357 26488358 26488359 26488364 26488365 26488366 26488367 25709436 25709437

48629615 48629626 63771576 63771588 63771592 63771629 63771624 63771617 63771570 63771616 52185535 52185541 52185557 52185542 63851783 67212999 63851787 67213000 67212970 42701052 63778323 67212998 63851800 63851799 63867366 63867371 63867382 63857574 42501104 68637805 42502548 68637825 42501097 68637806 42502547 68637826 63827114 63827113

697012089 2 1 697012089 2 1 697012089 2 1 699126861 3 1 699126861 3 1 699126861 3 1 699126861 3 1 999043937 5 1 999043937 5 1 999043937 5 1 999043937 5 1 697010260 1 1 697010260 1 1 697010260 1 1 697010260 1 1 697008023 7 1 697008023 7 1 697008023 7 1 697008023 7 1 699148954 0 1 699148954 0 1 699148954 0 1 699148954 0 1 695100454 5 1 695100454 5 1 697004511 5 1 697004511 5 1 697004511 5 1 697004511 5 1 999051530 7 1 999051530 7 1 999051530 7 1 999051530 7 1 697009847 8 1 697009847 8 1 697009847 8 1 697009847 8 1 999047451 3 1 999047451 3 1

039

.00

025

9.82

039

6.33

028

8.20

031

8.92

037

14.54

054

12.26

047

12.14

039

6.33

025

9.82

039

6.33

047

12.22

039

6.13

025

10.37

039

6.13

031

8.92

037

13.71

039

6.33

055

9.10

028

7.18

031

7.23

037

14.54

054

8.37

068

58.87

072

51.40

031

8.92

037

14.54

039

6.33

055

9.91

031

8.92

037

14.54

039

6.33

055

9.91

031

8.92

037

14.54

039

6.33

055

9.91

031

6.87

037

6.95

CLINIC PAGE 9 D/U/CL 09-1-259 RUN DATE 07/13/95

DATE ISSUED 04/06/95 04/14/95
04/14/95 04/14/95 04/14/95 04/06/95 04/06/95 04/05/95 04/06/95 04/06/95 04/06/95 04/06/95 04/06/95 04/12/95 04/12/95 04/12/95 04/12/95 04/11/95 04/11/95 04/11/95 04/11/95 04/06/95 04/06/95 04/06/95 04/06/95 04/11/.95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/10/95 04/10/95 04/10/95 04/10/95 04/06/95 04/06/95

STATUS DATE
05/10/95 04/18/95
04/14/95 04/18/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/19/95 04/19/95 04/19/95 04/12/95 04/13/95 05/01/95 04/13/95 05/01/95 05/01/95 05/26/95 04/10/95 05/01/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 04/10/95 04/10/95

CMNTS
EXP 04/18/95
VOID
VOID

TOTAL VOUCHERS CASHED TOTAL VOUCHERS EXPIRED TOTAL UNMATCHED TO CERT RECORDS TOTAL VOUCHERS ISSUED VOIDED UNCLAIMED TOTAL VOUCHERS CREATED

CLINIC TOTALS VOUCHERS
805 73 0
878 135
0 1,013

AMOUNT 11,199.66
.00 11,199.66
11,199.66

(TOTAL OF CASHED AND EXPIRED) (COMPUTED AND MANUAL VOUCHERS)

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GA WIC 2010 PROCEDURES MANUAL
GEORGIA WIC PROGRAM VOUCHER INVESTIGATION LOG

Attachment CA-2

DISTRICT/UNIT: ___________________DATE: ___________________________________ REASON FOR INVESTIGATION:

VOUCHER NUMBER

ISSUE DATE

CLINIC BOX

#

#

STATE WIC OFFICE USE ONLY

PAID YES/NO

COMMENTS

COMPLETED BY:

DATE: ____________________________
Routing : White Copy - State WIC Program, Yellow - Local Agency

Form 3789 (5-99)

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GA WIC 2010 PROCEDURES

Attachment CA-3

Dual Participation Sample Warning Letter

Dear Participant:
Our records show that you have participated on two Georgia WIC Programs. Your were certified and enrolled on the ___________________ Georgia WIC Program on (data) __________, and you were also certified and enrolled on the _________________Georgia WIC Program on (date) __________.
As indicated on your Georgia WIC ID card, participating on more that one Georgia WIC Program violates programs regulations. Information concerning this will be forwarded to the Compliance Analysis Section on the Georgia WIC Program to determine if you will be required to pay money back to the Georgia WIC Program.
Should you have any questions, contact me at _________________________________.
Sincerely
Nutrition Services Director

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GA WIC 2010 PROCEDURES

Attachment CA-4

Participant Fraud Sample Warning Letter

Dear Participant: It has come to my attention that you sold food that was purchased utilizing your Georgia WIC vouchers. This is against Georgia WIC Program regulations. The WIC foods are provided to your child to improve their nutrition status and overall health. The food must be given to the qualified child and not used for any other purpose. If you continue to sell your WIC food after this warning, your child may be taken off the Georgia WIC Program for up to three (3) months. If you have any questions, please call me at __________________________________.
Sincerely
Nutrition Services Director

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GA WIC 2010 PROCEDURES MANUAL

Attachment CA-5

REQUEST FOR INVESTIGATION FORM

GEORGIA WIC PROGRAM
WIC REQUEST FOR INVESTIGATION

TO:

FROM:

DATE:

NAME AND ADDRESS OF STORE (INCLUDE STREET, CITY, STATE AND COUNTY)

VENDOR NUMBER

NAME OF OWNER OR MANAGER ETHNIC MAKEUP OF STORE'S CLIENTELE

HAS STORE BEEN PREVIOUSLY INVESTIGATED?

YES

NO

ARE THERE OTHER STORES UNDER THE SAME OWNERSHIP WHICH ARE AUTHORIZED FOR

PARTICIPATION?

YES

NO

If Yes, fill in their names and address.

TYPES OF ABUSES FOR WHICH INVESTIGATION IS REQUESTED. OTHER INFORMATION USEFUL TO THE INVESTIGATOR (PROVIDE ADDITIONAL SHEETS IF NECESSARY)

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GA WIC 2010 PROCEDURES MANUAL

Voucher Number
Store Name and Address:-

Georgia Department of Community Health Division of Public Health
Georgia WIC Program
WIC TRANSACTION REPORT (WTR)
WTR Returned to WIC Agency:

Attachment CA-6 Vendor Number

1. At the Check-out counter there (was/were) person(s) in line ahead of me. On

, at about

. I entered the subject's store. I selected the item(s) specified below.

The food instrument indicated above was used for this transaction. The clerk sold the item(s) below at a total cost of (if available) $

. During checkout, the voucher was in

plain view of the clerk who served the investigator. The price of the items(s) were marked on the item(s) or shelf, for item(s) not marked, they were verified by:

2.

Time Entered Store:

Time Approached Checkout:

Time Left Store:

3. Check List

Y / N

Y / N

Y / N

Prices Marked on Foods or Shelf

Rang up Sale

Adequate Supply of WIC Foods on Shelf

Recorded Price on Voucher

Checked ID Cards

Gave Receipt to Investigator

4. Comments

5.

Description of Clerk (Approximate)

SEX

RACE

AGE

6. Other Identifying Information: 7. Identified During Transaction as (Title/Name):

ELIGIBLE ITEMS

SUMMARY OF PURCHASE

QUANTITY

BRAND NAME

HEIGHT

WEIGHT

ITEM

HAIR COLOR PRICE

INELIGIBLE ITEMS
QUANTITY

ITEM

PRICE

ITEMS REFUSED
QUANTITY

ITEM

I

, an investigator of the Georgia WIC Program, Department of Community Health,

make the above statement freely and voluntarily knowing that this statement may be used as evidence.

Name:

Date:

Title:

Investigator Signature:

Form 3773 (6/99)

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GA WIC 2010 PROCEDURES MANUAL

Attachment CA-7

GEORGIA WIC PROGRAM
PARTICIPANT ACCESS VERIFICATION FORM

District/Unit

Vendor Number

Name of Vendor under Investigation Address (Street/Hwy)

WIC Vendor(s) within ten (10) miles of Investigated Vendor

Vendor Name Address

Vendor Name Address

Distance In Miles Longitude Latitude
List any Geographical Barriers

Distances In Miles Longitude Latitude
List any Geographical Barriers

Explain the following observations
Sidewalks Crosswalks Traffic Lights Busy Highway(s) Concrete Medians Public Transportation Comments

Explain the following observations
Sidewalks Crosswalks Traffic Lights Busy Highway(s) Concrete Medians Public Transportation Comments

Investigator's Signature

Date

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GA WIC 2010 PROCEDURES MANUAL

Attachment CA-8

Product Milk

Type

Brand

GEORGIA DEPARTMENT OF COMMUNITY HEALTH
GEORGIA WIC PROGRAM DONATION LIST

Quant./ C.B. Date Vendor # Size

Items Purchased

Non WIC Foods Items

Type

Brand Quant./ Size

CB Date

Vendor #

Cereal
Peanut B./ Peas/ Beans Juice
Cheese Formula Eggs
Form 3818 (4/02) Please Use Ink

Other WIC Approved Items:
Comments: Organization Name: Organization Representative: Phone #: Address: City: WIC Representative: Date:
CA-24

Zip Code:

GA WIC 2010 PROCEDURES MANUAL

Attachment CA-9

Please use Ink
Georgia WIC Program
NOTIFICATION SUMMARY OF MISSING VOUCHERS/VOC CARDS

COMPLETE: When 25 or more WIC vouchers; 5 or more VOC cards; are missing. (A lost/stolen/voucher report must be completed for all missing vouchers)
IMMEDIATELY: Notify Supervisor; Nutrition Services Director; and the Police. Complete the following information: (ALL SECTIONS MUST BE COMPLETED)
SECTION I

Name of person who discovered the vouchers/VOC cards missing

D/U/C

Name of person completing this form, if different from above ________________________________________________________________
SECTION II

Name of person(s), who is responsible for vouchers/VOC cards at this clinic.

_____________________________________________________

________________________________________________

_____________________________________________________

________________________________________________

SECTION III

Number of Missing Voucher(s)

Number of Missing VOC Cards

NOTE: A separate form must be completed if both Vouchers and VOC cards are missing

Discovered missing:

Date

Time

am

pm

Supervisor notified:

Date

Time

am

pm

Coordinator notified:

Date

Time

am

pm

VOUCHER'S Beginning #

Ending #

VOC CARD'S Beginning #

Ending #

SECTION IV

Complete a detailed summary of how vouchers/VOC cards were discovered missing: ___________________________________________ _______________________________________________________________________________________________________________________________________

Use additional sheets of paper if needed, and attach

SECTION V
List any additional information that would apply to this case. ______________________________________________________________________________________________________________________________________

Use additional sheets of paper if needed, and attach

SECTION VI

Signature of person completing report:

__________________________________________________________________________________________________

(Submit completed report to Nutrition Services Director/Person in charge)

Person receiving the report:

Title:

(This signature is to verify receipt of this report, not to verify information on report)

Date:

WIC Coordinator or designee shall submit a copy of this report to the State WIC Office within three (3) working days.

Routing: White Copy - SWO

Pink Copy - District

Yellow Copy Clinic

Note:

In the event that unused vouchers are lost or stolen as a result of an unsecured food instrument environment, thus resulting in USDA sanctions to repay the value of the lost or stolen vouchers in question, the Local Agency will be responsible for repaying the value of those food instruments.

CA-25

GA WIC 2010 PROCEDURES MANUAL

Attachment CA-10

GEORGIA WIC PROGRAM

Duplicate Participation Verification Form

DISTRICT/UNIT: | | | | |

CLINIC: | | | | |

DATE: | | | | | | |

INSTRUCTIONS

- USE THIS FORM TO REMOVE PARTICIPANTS FROM THE DUPLICATE PARTICIPATION REPORT
- RETURN TO COVANSYS AS SOON AS POSSIBLE. - MAIL TO: COVANSYS COMPUTING, INC.
GEORGIA WIC Unit 1499 WINDHORST WAY, SUITE 240 GREENWOOD, IN 46142 - OR FAX TO: (317) 889-9485

THE FOLLOWING CLIENT(S) LISTED BELOW ARE LEGITIMATE PARTICIPANTS. PLEASE REMOVE THEM FROM SUBSEQUENT DUAL PARTICPATION REPORTS

PARTICIPANT ID NUMBER

PARTICIPANT NAME

CA-26

GA WIC 2010 PROCEDURES MANUAL
Participant Repayment SAMPLE LETTER

Attachment CA-11

CERTIFIED MAIL RETURN RECEIPT REQUESTED
Ms.

Date:

Dear Ms. :
We read an advertisement that you placed in the Swapper Newspaper selling 48 cans of Similac infant formula for $______ per can. Formula provided by WIC must not be sold by our participants.
Please return all 48 cans of formula to the health department or remit $______ to us by check or money order. This is the amount we paid for the formula.
If you are unable to make a full payment of $______, please contact your Local Health Department for a payment plan. The payment plan cannot extend more than 90 days from the date of this letter.
Please send a cashier's check or money order payable to:
Georgia WIC Program Your address
We are a service organization, and it is our intent to be of assistance to our participants. We expect your cooperation to help make the Georgia WIC Program work effectively.
Please call me at _____________ (your #) if you have any questions or need to establish a repayment schedule.
Sincerely,

Nutrition Services Director's Name Address

CA-27

GA WIC 2010 PROCEDURES MANUAL
Participant Repayment Schedule SAMPLE LETTER

Attachment CA-12

CERTIFIED MAIL RETURN RECEIPT REQUESTED
Ms.

Date

Dear Ms.

:

This letter confirms your proposal to repay $______ to the Georgia WIC Program in monthly installments of $_______. If you fail to make payments on time, the full amount will be due immediately. The following is the payment schedule that we will require you to follow until the full amount is recovered:

DATE

AMOUNT

DATE

AMOUNT

Total Please send a cashier's check or money order payable to the Georgia WIC Program and mail it to the following address:
Georgia WIC Program Your address
If you have any questions, please call me at ________________. Sincerely,
Nutrition Services Director's Name Address

CA-28

GA WIC 2010 PROCEDURE MANUAL

Attachment CA-13

DUAL PARTICIPATION REPORT INVESTIGATION FORM

Please complete and return the following information listed below. Please send the information to the requesting clinic as soon as possible.

DU/Clinic:

Name:

WIC ID:

Birth date:

Mother's Name:

Date of last voucher pickup:

Date of Issue:

Is this client active or terminated? (If terminated, indicate term date and term code)

Terminate:

Term code:

Has the client transferred into your area recently?

(If yes, give date; ___________________________)

Date of last certification:

Social Security number:

CA-29

GA WIC 2010 PROCEDURES MANUAL

Attachment CA-14

Georgia WIC Program Abuse Claims Payment Report

Name of Participant: ______________________ ID# ____________ Name of Vendor ______________________ Vendor # _________

DU# ______ DU# ________

Reason for claim: _________________________________________________

Amount of claim: ______________________________

Date of notification to participant: _________ Date fair hearing requested: _________

Date of final disposition of fair hearing/court mandate: ________________

Repayment Schedule Agreement

Due Date: ___________

Amount Due: ___________

Payment to be submitted by: Clerk of Court [ ] Participant [ ] Vendor [ ]

Date Paid: Amount Paid:

Balance Due:

Initials

COLLECTED FUNDS ARE DEPOSITED IN A GENERAL ACCOUNT FOR FARMER'S MARKET MATCH FUND

Collection ceased due to:
[ ] No longer cost effective [ ] Unable to locate participant [ ] Other ____________________

Date:_____________ Date:_____________ Date:_____________

Initials ________________ Initials ________________ Initials ________________

Was In-kind Service performed:

YES [ ] NO [ ]

If yes explain:___________________________________________________________ _______________________________________________________________________

CA-30

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GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

TABLE OF CONTENTS Page
I. Introduction ................................................................................................................BF-1 II. Definitions....................................................................................................................BF-1 III. State Agency ................................................................................................................BF-2
A. Breastfeeding Coordinator ............................................................................BF-2 B. Breastfeeding Promotion, Education and Support Responsibilities .......BF-3 IV. Local Agency ..............................................................................................................BF-5 A. Breastfeeding Coordinator ............................................................................BF-5 B. Breastfeeding Promotion, Education and Support Responsibilities .......BF-5 C. Training ...........................................................................................................BF-7 D. Breastfeeding Promotion, Education and Support Plan ..........................BF-7 V. Participant Education ................................................................................................BF-8 A. Participant Education Requirements ...........................................................BF-8 B. Documentation of Breastfeeding Services ................................................BF-10 VI. Participant Referral ..................................................................................................BF-11 A. Referrals .........................................................................................................BF-11 B. Documentation .............................................................................................BF-12 VII. Breastfeeding Materials and Resources ................................................................BF-12 A. Printed and Audio-Visual Materials ........................................................BF-12 B. Breastfeeding Equipment and Supplies ...................................................BF-12

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

Page VIII. Allowable Costs for the Promotion and Support of Breastfeeding ...................BF-14
A. Allowable Breastfeeding Promotion and Support Costs ........................BF-14
B. Documentation of Costs...............................................................................BF-16
IX. Documentation of Breastfeeding Rates..................................................................BF-16
A. Documentation of WIC Type ......................................................................BF-16
B. Documentation of Weeks Breastfed ...........................................................BF-17
Attachments
BF-1 Position Paper on Breastfeeding .............................................................................BF-19
BF-2 Sample Job Description: Senior Public Health Educator Lactation Consultant ................................................................................................BF-20
BF-3 Sample Job Description: District Breastfeeding Coordinator.............................BF-22
BF-4 Guidelines for Breastfeeding Promotion and Support in the WIC Program.............................................................................................................BF-25
BF-5 Breastfeeding Resources Recommended by the Office of Nutrition.................BF-37
BF-6 Allowable and Unallowable Costs for the Promotion and Support of Breastfeeding .............................................................................................................BF-40
BF-7 Issues to Consider When Providing Breast Pumps .............................................BF-41
BF-8 Status Change from Prenatal to Breastfeeding and Assignment of Priority to Breastfeeding Mother and Infant............................................................................BF-44
BF-9 Key for Entering Weeks Breastfed..........................................................................BF-47

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

I. INTRODUCTION
This section of the Procedures Manual defines the concept of breastfeeding promotion, education and support; and explains the requirements for providing lactation services to WIC Program participants.
Health professionals recognize that, in almost all circumstances, breastfeeding is the optimal method for ensuring proper infant nutrition, while simultaneously benefiting the lactating mother. The advantages of breastfeeding range from biochemical, immunological, and endocrinologic to psychosocial, developmental, hygienic, and economic. Human milk contains the ideal balance of nutrients, enzymes, immunoglobulins, anti-infective agents, anti-allergic substances, hormones, and growth factors. Further, breastmilk changes to match the changing needs of the infant. Breastfeeding provides a time of intense maternal-infant interaction. Lactation also facilitates the physiologic return to the pre-pregnant state for the mother. 1
Public Health staffs have a responsibility to provide services designed to optimize the health of their clients. Through the WIC Program they have a unique opportunity to influence decisions on infant feeding. As stated in the Division of Public Health Position Paper on Breastfeeding (Attachment BF-1) a sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.

II. DEFINITIONS
Breastfeeding promotion, education and support are components of a process through which individuals gain the understanding, skills and motivation necessary to be able to select breastfeeding as the preferred method of feeding, as well as to initiate and maintain breastfeeding for a significant period of time.
Federal Regulations (7 CFR 246.2) define a woman as breastfeeding if she feeds breastmilk to her infant(s) on average at least once every 24 hours. Relactation/induced lactation after a period of not breastfeeding or lactation by a woman who is not the biological mother of the infant also qualifies the woman as a breastfeeding mother.

1 Healthy People 2010: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.

BF-1

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

Exclusively Breastfed (EBF) Infant: an infant who is being fed breastmilk and who receives no formula (infant formula, exempt infant formula, or medical foods) from the WIC Program.
Mostly Breastfed (MBF) Infant: an infant being fed breastmilk and receiving from the WIC Program formula in amounts that do not exceed the maximum allowances for mostly breastfed infants which is approximately half (50%) of the formula allowance for fully formula fed (FFF) infants.
Fully Formula Fed (FFF) Infant: an infant receiving from the WIC Program formula in amounts that exceed the maximum allowances for mostly breastfed (MBF) infants.
Postpartum Woman: a woman up to six (6) months postpartum who is not providing breastmilk to her infant (who is classified as a fully formula fed [FFF] infant).
Mostly Breastfeeding Woman: a woman up to twelve (12) months postpartum who is providing mostly breastmilk to her infant and whose infant receives formula from the WIC Program in amounts that do not exceed the maximum formula allowances for mostly breastfed (MBF) infants.
Some Breastfeeding Woman: a woman up to six (6) months postpartum who is accepting for her infant formula that exceeds the maximum amount of formula allowed for mostly breastfed (MBF) infants. Her infant is classified as a fully formula fed (FFF) infant. After six (6) months postpartum, breastfeeding women described as doing "some breastfeeding" under this definition will not be issued WIC supplemental foods. However, such women are eligible to be recertified for the WIC Program as participants and to receive nutrition education and breastfeeding support.
Exclusively Breastfeeding Woman: a woman up to twelve (12) months postpartum who is providing breastmilk to her infant and whose infant classified as an exclusively breastfed (EBF) infant is not receiving any infant formula, exempt infant formula, or medical foods from the WIC Program.

III. STATE AGENCY
A. Breastfeeding Coordinator
The responsibility for coordination of statewide WIC breastfeeding activities is vested within the Georgia Department of Human Resources,

BF-2

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

Division of Public Health, Office of Birth Outcomes, Women's Health Unit.
A qualified nutritionist (Master's degree and Registered Dietitian, or eligible for registration) or nurse is designated as the State Breastfeeding Coordinator. The responsibilities of this person are to plan, direct and coordinate the breastfeeding promotion, education and support component of the WIC Program.
B. Breastfeeding Promotion, Education and Support Responsibilities
The following are the State Agency responsibilities for breastfeeding promotion, education and support:
1. Develop, implement and evaluate the State breastfeeding promotion, education and support plan. Periodically review and evaluate the plan, and make appropriate revisions as necessary.
2. Develop guidelines for local agency breastfeeding promotion, education and support plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency breastfeeding promotion, education and support plans on a periodic basis through on-site visits and reports.
4. Evaluate breastfeeding promotion, education and support services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for Competent Professional Authorities (CPAs), paraprofessional staff, and clerical staff at local clinics. Training and technical assistance provide CPAs with current information on the management of normal breastfeeding issues and special problems in lactation. It provides all staff with an understanding of the importance of promoting, and ways to promote, breastfeeding in a clinic setting.
6. Identify and develop resource and education materials for use by local agencies. Provide materials in languages other than English in areas where a substantial number of participants are nonEnglish speaking.

BF-3

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

7. Coordinate WIC breastfeeding promotion, education and support activities with related programs and professional groups such as hospitals, private medical organizations, the Cooperative Extension Service, professional organizations, advisory committees, La Leche League, and other breastfeeding support and advocacy groups, private lactation consultants, etc.
8. Develop and implement procedures to assure that encouragement to breastfeed is offered to all prenatal participants, unless medically contraindicated.
9. Perform and document evaluation of breastfeeding promotion, education and support activities for each local agency on an annual basis. The evaluations shall include an assessment of the participant's views concerning the effectiveness of the education they received.
10. Establish standards for participant contact that ensure adequate breastfeeding education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant breastfeeding education contacts.
12. Establish breastfeeding promotion, education and support standards that include, at a minimum, the following:
a. A policy that creates a positive clinic environment which endorses breastfeeding as the preferred method of infant feeding.
b. A requirement that each local agency designate a staff person to coordinate the breastfeeding promotion and support activities.
c. A requirement that each local agency incorporate taskappropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC clients.
d. A plan to ensure that women have access to breastfeeding promotion, education, and support activities during the prenatal and postpartum periods.

BF-4

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

IV. LOCAL AGENCY
A. Breastfeeding Coordinator
1. Each local agency must designate a staff person to coordinate breastfeeding promotion, education and support activities. The breastfeeding coordinator position may be a qualified nutritionist, nurse, health educator, Certified Lactation Counselor (CLC), or International Board Certified Lactation Consultant (IBCLC). Attachment BF-2 lists a job description for Health Educator Senior/Lactation Consultant, which may be used to assure an individual is qualified to fill this position. A Georgia Gain job classification sample job description entitled District Breastfeeding Coordinator can be found in Attachment BF-3.
2. It is recommended that this position be designated as a full-time position in order to facilitate coordinating services throughout the local agency and across program lines and to adequately meet Federal requirements.
3. It is recommended that the breastfeeding coordinator be, or work towards becoming an International Board Certified Lactation Consultant (IBCLC). At a minimum, the breastfeeding coordinator should complete the Lactation Specialist Self Study Series, which has been provided to each local agency by the Office of Nutrition, or pass a Certified Lactation Counselor (CLC) course.
4. It is recommended that the breastfeeding coordinator work across program lines to provide breastfeeding services, thus increasing opportunities for all current and potential WIC participants to be reached. This will also serve to integrate services, and assure that all clinic staff receive appropriate training and deliver consistent information on breastfeeding.
B. Breastfeeding Promotion, Education and Support Responsibilities
The Georgia WIC Program is committed to the implementation of the Guidelines for Breastfeeding Promotion and Support in the WIC Program, developed by the National WIC Association (NWA) Breastfeeding Promotion Committee (Attachment BF-4). The local agencies are encouraged to use the Guidelines in carrying out the following breastfeeding responsibilities:

BF-5

GA WIC 2010 PROCEDURES MANUAL

Breastfeeding

1. Establish and maintain a positive clinic environment that clearly endorses and supports breastfeeding as the preferred method of infant feeding (NWA Guidelines #2, #4).
a. It is important to assure that relevant education materials available to participants portray breastfeeding as the preferred infant feeding method. The following items must be free of formula product names: print and audiovisual materials, and office supplies such as cups, pens, badge holders, pins, posters and note-pads.
b. Staff should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, staff should support her decision, and provide appropriate information.
c. The local agency must minimize the visibility of formula and bottle-feeding equipment through storing supplies of formula, baby bottles and nipples out of view of participants.
d. Staff must not accept formula from formula manufacturer representatives for personal use.
e. Staff should make every effort to provide a supportive environment in which women feel comfortable breastfeeding their infants. The clinic waiting area should be used advantageously to motivate women to recognize breastfeeding as the "norm" rather than the exception. The clinic area should, where space permits, also be used to provide worksite support for staff who are breastfeeding.
2. Incorporate task-appropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC participants (NWA Guideline #1).
3. Develop a plan to ensure that women have access to breastfeeding promotion and support activities during the prenatal and postpartum periods (NWA Guidelines #3, #5-9).
4. Submit, on an annual basis, a local agency plan of activities (See IV. D., below).

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C. Training
1. Orientation
All staff that interact with WIC applicants and participants must receive basic information on breastfeeding, during their orientation to the WIC Program.
a. Clerical and other non-CPA staff must receive training on maintaining a positive clinic environment, a positive and supportive attitude towards breastfeeding, and what they can do to promote and support breastfeeding in the clinic.
b. CPAs must receive, in addition to the above information, training on basic skills in getting women started with breastfeeding, assessment, problem solving, and followup and referrals.
2. Continuing Education
a. All staff are encouraged to attend local, State or National workshops for the purpose of developing and updating skills and knowledge in lactation management.
b. All breastfeeding training and continuing education activities conducted or attended by local staff must be recorded and kept on file by the local agency. The file should include the names and titles of the workshop participants, and the titles and dates of the workshops (see Attachments NE-6 for recommended forms).
D. Breastfeeding Promotion, Education and Support Plan
1. Annual Plan of Activities
The State Agency develops an annual Breastfeeding Promotion, Education and Support Plan, which incorporate both Federal Regulations and objectives/activities requested by the local agencies. In order to integrate efforts being conducted at both the State and the local levels, local agencies shall submit to the State, a Plan of Activities based on the State Plan objectives, and recommendations for additions or changes to the State Plan. A Breastfeeding Promotion, Education and Support Plan must be

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submitted to the WIC Program by the end of each year. This Plan should be incorporated in the local agency strategic plan for WIC and nutrition services.

V. PARTICIPANT EDUCATION
A. Participant Education Requirements
1. Each local agency must have an established reference guide for breastfeeding education. Examples of approved breastfeeding reference guides include, but are not limited to: x ADA Nutrition Care Manual x The Georgia Dietetic Association Nutrition Manual
2. All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons. As recommended in the established reference materials, encouragement to breastfeed should continue throughout the prenatal period. As stated in the Healthy People 2010 National Health Promotion and Disease Prevention objectives for breastfeeding, breastfeeding is not appropriate for infants whose mothers use drugs illicitly, or who receive certain therapeutic or diagnostic agents such as radioactive elements and cancer chemotherapy.2 Women who are HIV positive, according to the Centers for Disease Control and Prevention guidelines, should also avoid breastfeeding.
3. As part of the prenatal breastfeeding education, the following information must be offered on WIC benefits for breastfeeding women:
a. Breastfeeding women are at a higher level in the priority system than non-breastfeeding postpartum women, and are more likely to be served than these women when local agencies do not have the resources to serve all qualified individuals.
b. Exclusively breastfeeding women (whose infants receive
2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.

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no formula from the WIC Program) and mostly breastfeeding women (whose infants receive formula from the WIC Program in amounts that do not exceed the maximum formula allowance for mostly breastfed [MBF] infants) may receive WIC supplemental food benefits for up to twelve (12) months postpartum, or until breastfeeding is discontinued. Non-breastfeeding women and women classified "some breastfeeding" are both receiving formula from the WIC Program that exceeds the maximum allowance for mostly breastfed (MBF) infants and thus are eligible for supplemental foods for only six (6) months postpartum.
c. The WIC Program offers a greater variety and quantity of food to those breastfeeding participants who are classified as "mostly" or "exclusively" breastfeeding than to nonbreastfeeding, postpartum participants and to women classified as doing "some breastfeeding."
4. Breastfeeding women should be taught hand expression of breastmilk. All CPAs, breastfeeding counselors and nutrition assistants should be trained to teach hand expression of breastmilk. However, if a staff person is not skilled in this area, a referral should be made to trained staff or the local agency breastfeeding coordinator.
5. Breastfeeding women must be taught signs of adequate intake by the breastfed infant. Signs of adequate intake are:
a. baby is nursing 8-12 times per 24 hours b. baby wets diaper at least six (6) or more times per 24
hours c. baby has three (3) or more stools per 24 hours, in first
month d. baby has visible and audible signs of swallowing e. mother's breasts feel softer after feeding f. baby has adequate weight gain over time (for infants who
are presented for weight checks).
6. Breastfeeding education contacts must be provided by a nutritionist, registered dietitian, competent professional authority; or other certified health professional, peer counselor or nutrition assistant who has been trained by the State or local

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agency.
7. Local agencies are encouraged to use peer counselors trained by the State or local agency to provide encouragement, education, and support to prenatal and breastfeeding women.
8. Nutrition assistants can also provide breastfeeding education and support when appropriate training has been received. The Office of Nutrition and State Breastfeeding Coordinator must approve the training plan. See Attachment NE-3 for the Guidelines for Nutrition Assistant Training and list of items to be submitted for approval.
9. An individual care plan should be developed for a participant based on the need, as determined by the competent professional authority. The Care Plan should be written in the progress notes, preferably using the SOAP (Subjective - Objective - Assessment Plan) note format.
10. Class outlines must be developed when group-facilitated classes are used to provide the breastfeeding education contact. Class outlines must be kept at the clinic site for use by clinic staff and provided to the Office of Nutrition at the time of program reviews.
11. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing breastfeeding education contacts.
12. Local agencies are also encouraged to provide ongoing lactation support for prenatal and breastfeeding women by telephone. If possible, a breastfeeding help line should be established to facilitate access to information and support services.
B. Documentation of Breastfeeding Services
1. All breastfeeding education and support contacts received by participants must be documented in the participant's health record.
a. In order to facilitate continuity of care, documentation of encouragement to breastfeed should include all aspects of

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breastfeeding discussed with the participant (e.g., barriers to breastfeeding, emotional/nutritional advantages, positioning).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
c. Group-facilitated breastfeeding education classes must be documented in the participant's health record and should be validated with the participant's signature on a class attendance sheet. There must also be a class description with date, group-facilitated class objective(s) and original signature of the staff person leading the group-facilitated class.
2. Missed appointments for breastfeeding education contacts and the refusal of a participant/caregiver to receive breastfeeding education must be documented in the participant's health record. Documenting missed appointments and refusal to receive education are important for the purpose of monitoring and further education efforts. However, failed, missed, and refused breastfeeding education contacts do not count has having provided breastfeeding education or secondary nutrition education.

VI. PARTICIPANT REFERRAL
A. Referrals
1. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.
2. Local agencies are encouraged to identify and develop a list of breastfeeding resources for prenatal and breastfeeding women. This list may include hospital staff, physicians, local support groups (both informal and organized, such as La Leche League), public health staff with expertise in handling breastfeeding questions, sources for breast pumps, peer counselors, etc.
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B. Documentation
Referrals to and enrollment in other health services and programs must be documented in the participant's health record. A decision not to refer or a refusal by the participant must also be documented.

VII. BREASTFEEDING MATERIALS AND RESOURCES
A. Printed and Audio-Visual Materials
Standards for the development and use of printed and audio-visual breastfeeding materials are the same as those used for Nutrition Education materials (See VIII. in the Nutrition Education Section for information). In addition:
1. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method.
2. The following items must be free of formula product names: print and audiovisual materials, and office supplies such as cups, pens and note-pads. Staff should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern.
3. The local agency must minimize the visibility of formula and bottle-feeding equipment through storing supplies of formula, baby bottles and nipples out of view of participants.
Attachment BF-5 provides a list of resources that are recommended for use by the Office of Nutrition and Women's Health Unit.
B. Breastfeeding Equipment and Supplies
1. Allowable Costs
Local agencies are encouraged to assess the need for breastfeeding equipment and supplies. Providing equipment and supplies should not generally be the primary means by which the State and local agencies meet their breastfeeding

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promotion and support target expenditures. Breastfeeding aids should be used in conjunction with appropriate counseling, education, and follow-up provided by trained staff.
Breast pumps and other breastfeeding aids may not be provided to all pregnant or breastfeeding women solely as an incentive to consider or to continue breastfeeding.
The policy on allowable costs for the promotion and support of breastfeeding is explained in VIII. below, and in the Administrative Responsibilities section of the Procedures Manual. Attachment BF-6 provides a list of allowable and unallowable costs, as specified in the Federal Regulations.
2. Breast Pumps
Local agencies are encouraged to have a supply of manually operated and electric pumps on hand for situations that merit their use. It is neither necessary nor desirable to give breast pumps to every breastfeeding or potential breastfeeding mother. Some situations in which availability of a breast pump may be necessary to assure continuation of milk production are:
a. Mothers who have temporary breastfeeding problems, such as engorgement. These are situations in which hand expression or a manual pump may be all that is needed.
b. Mothers who are having difficulty in establishing or maintaining an adequate milk supply due to maternal illness or a premature/sick infant.
c. Mothers with inverted/flat nipples who are having latchon problems.
d. Mothers attempting to build their milk supply for any reason.
e. Mothers choosing to express breastmilk for missed feedings due to work, school or maternal hospitalization, or if temporary weaning is necessary.
Breast pumps are not a direct program benefit that State agencies are required to provide but rather are aids that may be offered to

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certain WIC participants to facilitate breastfeeding. The pumps may be offered free or at cost to WIC participants. Issues to consider when providing breast pumps are explained in Attachment BF-7.
3. Instructions for Breast Pump Use
Local agencies with breast pump loan and give-away programs must establish written policy and procedures regarding appropriate use, and instructions to be provided to breast pump recipients. The following must be included in the policy and procedures:
a. A trained, designated staff person is to provide instructions to the breastpump recipient on the proper use, assembly and cleaning of the breast pump.
b. The participant receiving the breast pump should be able to demonstrate the proper usage of the breast pump before leaving the issuing facility.
c. Follow-up within a 24-hour period is recommended, to assure that the pump is operating correctly and that the mother is using it properly.
4. Equipment and Supplies Inventory
Local agencies should maintain an inventory of all breastfeeding equipment and supplies. It is recommended that the inventory be updated on a quarterly basis. An inventory of breast pumps and attachment kits must be submitted to the Women's Health Unit by October 31st and March 31st of every year.

VIII. ALLOWABLE COSTS FOR THE PROMOTION AND SUPPORT OF BREASTFEEDING A. Allowable Breastfeeding Promotion and Support Costs
State WIC Program expenditures that are classified and reported as breastfeeding promotion and support, and may count toward the BFPS spending requirement include, but are not limited to, the following:
Salaries:
1. Salary and other costs for time, including preparation and travel

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time, spent on BFPS training and consultations, both individual and group.
2. Salary and other costs, for staff to organize volunteers and community groups to support breastfeeding WIC participants.
3. Salary and benefit expenses of peer counselors and individuals hired to undertake home visits and other actions intended to assist women to continue breastfeeding.
4. Salary and other costs incurred in developing the BFPS portion of the State Plan and local agencies' BFPS action plans.
5. Interpreter or translator services to facilitate breastfeeding promotion and support.
Training:
6. Costs of training BFPS educators, including costs related to conducting training sessions and purchasing and producing training materials.
Space and Facilities:
7. Costs of clinic space devoted to BFPS education and training activities, including space set aside for breastfeeding WIC infants.
Materials and Equipment:
8. Costs of procuring and producing BFPS materials and equipment.
9. Breastfeeding aids which directly support the initiation and continuation of breastfeeding. See Attachment BF-6 for a list of allowable and unallowable breastfeeding aids.
Monitoring and Evaluation:
10. Costs of documenting, monitoring, and/or evaluating BFPS staff, activities, methods and materials. This includes the cost of collecting, analyzing and evaluating data concerning WIC participants' opinions on the effectiveness of the BFPS they received and the incidence and duration of breastfeeding for WIC

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participants, to assess the effectiveness of breastfeeding promotion, education and support efforts.
Travel:
11. Travel and related expenses incurred by WIC staff to conduct any BFPS activity.
Other Sources:
12. Costs of reimbursable agreements with other organizations, public or private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.
B. Documentation of Costs
The State and local agencies must document all Federal WIC grant funds expended to meet the minimum BFPS requirement. Documentation is necessary so that the WIC State Agency can clearly demonstrate the expenditure requirement has been satisfied. Salary costs identified and reported as being for BFPS activities must be supported with employee payroll and time distribution records. Costs such as equipment purchases and travel must be supported with accounting records, including source documents such as invoices and travel statements.

IX. DOCUMENTATION OF BREASTFEEDING RATES
The Georgia WIC Program documents breastfeeding rates by two different methods: percentage of women who are certified as breastfeeding (WIC Type B), and selfreported information on weeks breastfed (initiation & duration). It is important that documentation be accurate in both instances since they have a major impact on administration of the WIC Program. These two methods are described below:
A. Documentation of WIC Type
The State agency must have breastfeeding promotion and support expenditures which are based on the number of prenatal (WIC Type P) and breastfeeding women (WIC Type B) on the WIC Program. In addition, the Southeast Regional Office of USDA monitors changes in breastfeeding rates based on the number of women who are listed as breastfeeding (WIC Type B on the WIC System). Breastfeeding women

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should be entered into the system in the following ways:
1. Status Change from Prenatal (P) to Breastfeeding (B) During Subsequent Certification: A prenatal woman gives birth and is being certified as breastfeeding, within six weeks postpartum.
2. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification: When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an Update to the system. This should occur as soon as the local agency is made aware of the participant's change in status, as it will enable the program to capture those women who initiate breastfeeding, but may discontinue breastfeeding by their subsequent certification. A subsequent certification is not required in order to simply change the participant's status from P to B, as long as she is less than six (6) weeks postpartum.
Note: This action does not exclude the participant from the required postpartum subsequent certification. See Attachment BF-8 for instructions on making the status change.
3. Assignment of Breastfeeding Status During Certification: A woman was not on the program while she was pregnant but is being certified as a breastfeeding woman.
Note: A woman and her infant(s) can be certified as breastfeeding: (1) if the definition of breastfeeding is met, and (2) based on the quantity of formula her infant is receiving from the WIC Program (See II. DEFINITIONS).
B. Documentation of Weeks Breastfed
The State agency uses this information to monitor changes in breastfeeding initiation and duration rates by State, local agency and individual clinic sites. This information is very useful in program planning and targeting of resources. The Infant Breastfeeding Characteristics Report, which includes this information, is sent to the local agencies on a monthly basis.
It is critical that all staff who complete the WIC Assessment/Certification Forms and the Turnaround Documents be instructed on the importance

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of, and the process for, accurate documentation of weeks breastfed.
It is a requirement that the weeks breastfed be recorded on the WIC Assessment/Certification Form and the Turnaround Document for:
1. Breastfeeding women: initial and six-month certification visits
2. Postpartum, non-breastfeeding women: certification visit
3. Infants: initial certification and mid-certification assessment visits
4. Children: i one year of age subsequent certification visit (11 - 16 months of age), if they participated as infants i at initial certification (any age), if they did not participate as infants
Participants/caregivers should be asked about weeks breastfed, using the following, or similar words: "How long have you breastfed this baby/child?" or "How long has this baby/child been breastfed?" The length of time breastfed must be entered in weeks. When the answer to the question is given in days or months, this information must be converted to weeks. See Attachment BF-9 for appropriate codes to use for weeks breastfed.

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Attachment BF-1

POSITION PAPER ON BREASTFEEDING
If the children of Georgia are to be healthy and strong, it is essential that they receive the best possible nutrition when they are infants. Breast milk is the appropriate first food for the human infant. In addition to the nutritional benefits for the infant, this method of feeding offers unique physiological and psychological advantages to both the mother and the infant. Every infant, therefore, should receive the benefits of this ideal choice for infant feeding. This paper presents the recommendations of the State of Georgia for encouraging breastfeeding and defines the advantages of breastfeeding for the health of mothers and infants.
No formula, no matter how "humanized", can take the place of human milk. Decreased infant mortality and optimum infant health are the most important goals of the Division of Public Health. Breastfeeding can contribute significantly to the achievement of these goals because:
i breast milk provides an ideal balance of nutrients for the human infant. i the nutrients in breast milk are easily absorbed and digested. i breast milk contains immune factors and anti-infective properties that protect against
infections. i breastfeeding allows the satiety mechanism in the infant to develop naturally. i infants who are breastfed have fewer allergies. i breastfeeding promotes increased bonding between mother and infant. i breast milk is safe, sanitary food.
A sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods. Based on the World Health Organization/United Nations International Children's Fund (WHO/UNICEF) 1979 meeting on Infant and Young Child Feeding, the WHO 1981 Resolution and the recommendation of the American Academy of Pediatrics Committee on Nutrition, the Georgia Department of Human Resources recommends that:
i breast milk be the "house formula" in all hospitals in Georgia where maternity services are offered
i all expectant parents be informed of the numerous advantages (both to infant and mother) of breastfeeding.
i every expectant mother receive practical information on how to initiate and maintain lactation. i obstetrical procedures and practices be consistent with the policy of promoting breastfeeding. i breastfeeding be initiated as soon as possible, preferably during the first hour after birth. i every hospital permit and encourage rooming-in and on-demand feeding of breastfed infants. i infant formulas not be marketed or distributed in ways that may interfere with the
protection and promotion of breastfeeding. i places of business, including government offices, facilitate the maintenance of lactation
through liberalized policies that would promote breastfeeding.
All the available knowledge indicates that breastfeeding is the best choice for infant feeding and should be promoted for mothers and infants of the State. Breast milk as this choice for infant nutrition will promote optimum health for future generations of Georgians.

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Attachment BF-2

SAMPLE JOB DESCRIPTION SENIOR PUBLIC HEALTH EDUCATOR - LACTATION CONSULTANT

The examples of work given are illustrative of the duties assigned to positions of this class. No attempt is made to be exhaustive. The intent of the listed examples is to give a general indication of the levels of difficulty and responsibility common to all positions of this class.

The standards for training and experience express the minimum background necessary as evidence of an applicant's ability to qualify for positions of this class. Unless otherwise stated, the Applicant Services division may allow substitution of appropriate education or experience for the training and experience minimum listed.

DEFINITION

Under direction, performs work of moderate difficulty in planning and implementing breastfeeding education activities related to public health programs; and performs related work as required.

EXAMPLES OF DUTIES

I.

Coordinates breastfeeding promotion project. Writes, revises, and evaluates the district's

breastfeeding services.

A. Establishes relationships with community health centers and/or hospital staff to provide breastfeeding services.

B. Provides in-service education material and/or needed equipment on breastfeeding for staff development.

C. Responsible for keeping daily communication sheets regarding telephone calls, correspondence, patients seen, meetings, and work related to breastfeeding funds.

II. Promotes breastfeeding services as an integral part of perinatal care.

A. Encourages all prenatal women, on their initial visit, to breastfeed by providing an array of educational material and counseling.

B. Provides additional breastfeeding counseling to prospective breastfeeding women during the last trimester through breastfeeding classes and/or individual counseling.

C. Provides postpartum assessment of breastfeeding dyad, education, and assistance in resolving problems upon request. Provides adequate documentation of services and makes appropriate referrals for continuity of care.

D. Develops and implements continuing education and support networks through a variety of methods, such as support groups, peer counselors, etc.

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Attachment BF-2 (cont'd)

E. Supervises and trains peer counselors.
F. Has ability to communicate effectively in writing, including grant proposals.
III. Evaluates effectiveness of breastfeeding program activities.
A. Produces reports to determine breastfeeding rate and duration.
B. Assists WIC Nutrition Coordinator in writing the breastfeeding promotion plan and annual update of breastfeeding activities.
C. Shares reports at local district meetings and Statewide breastfeeding conferences.
IV. Attends in-service education programs and annual Statewide breastfeeding conferences.
V. Other miscellaneous duties, activities and responsibilities as program needs develop and change, and as assigned.
MINIMUM QUALIFICATIONS: NECESSARY KNOWLEDGE, SKILLS, AND ABILITIES
Considerable ability to assess the effectiveness and needs of a lactation promotion and education program and to plan and implement appropriate changes and improvement; and to assess and counsel an individual.
Considerable skill in the organization and preparation of lactation literature and visual aids; in making oral presentations of instructional programs to the general public and to other health specialists.
Good knowledge of educational program development and implementation as related to the preparation of health education displays, lectures, written material, and classroom programs; of data collection and evaluation techniques appropriate to the assessment of the breastfeeding program.
Good working skills in communicating effectively with the professional staff, general public and para-professionals; in use of educational literature and visual aids; in making oral presentations of instructional programs; in making recommendations for equipment needs; and in ability to budget.
TRAINING AND EXPERIENCE
Completion of a master's degree in public health, education, nursing, nutrition or a field directly related to public health activities. Certified as an International Board Certified Lactation Consultant or eligible for certification within two years. Has successfully completed the State certified lactation counselor (CLC) course or equivalent.

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Attachment BF-3

SAMPLE JOB DESCRIPTION
JOB TITLE: DISTRICT BREASTFEEDING COORDINATOR
GENERAL SUMMARY Under general supervision, plans, develops, implements and evaluates strategies for promoting and supporting breastfeeding among the high risk, low income population, especially prenatal/breastfeeding women and infants.
RESPONSIBILITIES AND STANDARDS
Responsibility Number 1 (All) Develops long and short-term goals for breastfeeding promotion and supports activities for the district.
STANDARDS:
1. Works closely with the supervisor to develop an appropriate District Breastfeeding Promotion and Support Plan.
2. Coordinates breastfeeding services among all clinic sites to ensure efficiency of services provided.
3. Accurately interprets federal/state regulations to ensure adherence to these.
4. Makes sound and defensible recommendations to the supervisor regarding the breastfeeding budget.
5. Develops continuing education, support networks for mothers and networks for professionals in breastfeeding promotion and support.
Responsibility Number 2 (Some) Implements breastfeeding promotion and support plans, to include staff development, community networks and services to clients.
STANDARDS:
1. Provides in-service education, materials and/or needed equipment for staff development in a timely manner.
2. Establishes a good working relationship with community health centers and/or hospital staff to assure continuity of breastfeeding services to clients.
3. Serves as the District's primary resource person regarding breastfeeding education and support by providing prompt responses to inquiries.
4. Provides direct services to clients through prenatal classes, individual instruction, referral

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Attachment BF-3 (cont'd)

for appropriate case, telephone consultations according to established laws and guidelines.
5. Coordinates pump loan program to ensure maximum usage of available pumps and instructs both staff and clients on use of breast pumps as needed.
6. Serves as primary resource person to health department staff regarding current recommendations and information in breastfeeding management.
Responsibility Number 3 (All)
Works closely with the supervisor to evaluate the effectiveness of breastfeeding program activities.
STANDARDS:
1. Monitors reports to accurately determine breastfeeding rates by county, district, and state.
2. Writes the annual progress report on the breastfeeding promotion and support plan by providing appropriate input in a timely manner.
3. Maintains necessary reports and data for the purpose of documenting incidence and duration of breastfeeding, client-centered activities, activities conducted with other agencies, community groups and local hospitals, and training conducted.
Responsibility Number 4 (All) Creates and maintains a high performance environment characterized by positive leadership and a strong team orientation.
STANDARDS:
1. Defines goals and/or required results at beginning of performance period and gains acceptance of ideas by creating a shared vision.
2. Communicates regularly with staff on progress toward defined goals and/or required results, providing specific feedback and initiating corrective action when defined goals and/or results are met.
3. Confers regularly with staff to review employee relations climate, specific problem areas and actions necessary for improvement.
4. Evaluates employees at scheduled intervals, obtains and considers all relevant information in evaluations and supports staff by giving praise and constructive criticism.
5. Recognizes contributions and celebrates accomplishments.
6. Motivates staff to improve quantity and quality of work performed and provides training and development opportunities as appropriate.

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Attachment BF-3 (cont'd)

Responsibility Number 5 (All)
Maintains responsibility for personal professional continuing education to enable application of current practice.

STANDARDS:

1. Participates in professional workshops, seminars, staff meetings and other in-services as scheduled. Summarizes relevant information received in training sessions; shares with other staff either in verbal or written form.

2.

Remains knowledgeable and up-to-date in the field of nutrition through reading nutrition and

medical journals and textbooks.

3.

Maintains CPR certification and proficiency by renewing certification bi-annually.

MINIMUM QUALIFICATIONS:

Completion of an undergraduate degree in dietetics, nursing, community health nutrition, or health education at a four year college or university AND Two years of professional experience in the provision of nutrition or nursing services, one of which was in a community health setting.

Licensure/Certification: Registered Dietitian; Registered Professional Nurse; CHES

Preferred Qualifications:

Current status as an International Board Certified Lactation Consultant or Certified Lactation Counselor

A minimum of one year of experience providing breastfeeding education, lactation counseling and assessments and peer counselor supervision in a hospital or community health setting.

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Attachment BF-4

POSITION PAPER NATIONAL WIC ASSOCIATION
Guidelines for Breastfeeding Promotion and Support in the WIC Program
These guidelines were developed to assist local and state WIC agencies initiate and strengthen breastfeeding promotion and support programs. The guidelines address training, clinic environment, coordinated efforts, program evaluation, breastfeeding education and support, and the food packages for breastfed infants and breastfeeding women. The guidelines are numbered for easy reference and are listed in random order. Therefore, the numbering system does not reflect rank order or priority.
GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding as the preferred method of infant feeding.
GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and endorse breastfeeding as the preferred method of infant feeding.
GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations.
GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials, and outreach efforts.
GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.
GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.
GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

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Attachment BF-4 (cont'd)

GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.
GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.
SUGGESTIONS FOR IMPLEMENTATION
GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding promotion and support.
Suggestions for Implementation
1. It is important to develop orientation guidelines for new WIC employees that address: i clinic environment policies i program goals and philosophy regarding breastfeeding i task-appropriate information
Rationale: All new employees (support staff, paraprofessionals and professionals) must be familiar with program policies, goals and philosophy regarding breastfeeding. When all program staff project a positive attitude about breastfeeding, clients will be more comfortable discussing their breastfeeding questions and concerns.
2. It is important that the state agency develop guidelines for on-going training that address: i culturally appropriate breastfeeding promotion strategies i current breastfeeding management techniques to i encourage and support the breastfeeding mother and infant i appropriate use of breastfeeding education materials i identification of individual needs and concerns about breastfeeding
Rationale: Ongoing training for staff providing breastfeeding education is needed because information about breastfeeding education continues to evolve. Addressing specific ethnic and culturally based needs fosters appropriately targeted messages in print and audiovisual materials.
3. It is important that local agency staff participate in breastfeeding training such as:

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Attachment BF-4 (cont'd)

i statewide and local conferences and workshops i events sponsored by other agencies and organizations
Rationale: Local agencies' participation in breastfeeding training is essential to successful implementation of breastfeeding promotion programs.
4. It is important that the local agency and state agency appoint a breastfeeding coordinator.
Rationale: Appointing a breastfeeding coordinator helps ensure that breastfeeding promotion and support activities are integrated into WIC program operations. The specific responsibilities and tasks of breastfeeding coordinators will vary from agency to agency based on their breastfeeding promotion and support activities. Breastfeeding coordinators should participate in training opportunities related to their job responsibilities.
GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and breastfeeding as the preferred method of infant feeding.
Suggestions for Implementation
1. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method. Consider: i print and audiovisual materials free of formula product names i office supplies such as cups, pens, and note-pads free of formula product names
Rationale: Use of materials with product names sends a mixed message to clients and staff and might unconsciously put up barriers to breastfeeding.
2. It is important to establish a positive attitude toward breastfeeding in WIC clinics.
Rationale: Health care workers should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, WIC staff should support her decision.
3. It is important that the local agency minimize the visibility of formula and bottlefeeding equipment. Consider: i storing supplies of formula out of view of participants i storing baby bottles and nipples out of view of participants
Rationale: Formula and bottle-feeding equipment in clear view of participants

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Attachment BF-4 (cont'd)

may influence a mother's decision on infant feeding.
4. It is important that staff not accept formula from formula manufacturer representatives for personal use.
Rationale: Acceptance of formula for personal use may influence staff to endorse a particular product, either consciously or unconsciously. Acceptance of formula also conflicts with the program's breastfeeding promotion and support activities.
5. It is important that the local agency try to provide a supportive environment in which women feel comfortable breastfeeding their infants. Consider: i chairs with arms i a breastfeeding area away from the entrance
Rationale: The clinic waiting area can be used advantageously to motivate women to recognize breastfeeding as the "norm" rather than the exception. The clinic area can also be used to provide worksite support for breastfeeding WIC staff.
6. It is important that the state agency assist local agencies in obtaining culturally sensitive and appropriate and translated breastfeeding education materials.
Rationale: The language and pictures in breastfeeding education materials should be relevant to the target population served by the program.
GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations providing care and support for women, infants and children.
Suggestions for Implementation
1. It is important for local and state agencies to participate in and support coordinated activities with appropriate groups such as: i task forces, networks, or steering committees to exchange information and strategies i professional health organizations to secure resources and expertise and assure communication with health professionals serving pregnant and breastfeeding women i existing peer support groups to facilitate local exchange of breastfeeding information across the state i community leaders and citizen groups who support breastfeeding i the Breastfeeding Promotion Consortium and its efforts, including a national

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Attachment BF-4 (cont'd)

breastfeeding promotion campaign
Rationale: A collaborative approach to breastfeeding promotion can create a strong supportive climate and help ensure more effective use of all available resources.
2. It is important that the state agency disseminate information such as the NAWD position paper, Breastfeeding Promotion in the WIC Program and the Guidelines for Breastfeeding Promotion in the WIC Program to state and local affiliates of groups such as: i American Academy of Pediatrics i American Academy of Family Physicians i American college of Nurse Midwives i American College of Obstetricians and Gynecologists i American Dietetic Association i American Hospital Association i American Nurses Association i American Public Health Association i Association of Pediatric Nurse Practitioners i Association of Women's Health and Obstetrics Nurses i Healthy Mothers, Healthy Babies Coalitions i International Lactation Consultants Association i La Leche League International i Maternal and Child Health Directors i Medicaid Directors i National Association of Pediatric Nurse Associates and Practitioners
Rationale: Serving as an adjunct to health care is a vital component of the WIC Program. Therefore, it is important that the program's health-related policies be shared with appropriate health care programs and professional organization. such interaction encourages a strong cooperative working relationship with the health community to accomplish mutual goals.
3. It is important for local and state WIC agencies to participate in and support coordinated breastfeeding promotion and support activities such as:
i co-sponsoring training and continuing education programs i sharing breastfeeding education materials for clients i developing local or state documents such as position statements, policies, model
hospital policies and counseling and referral protocols
GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages

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Attachment BF-4 (cont'd)

are incorporated in relevant educational activities, materials and outreach efforts. Suggestions for Implementation
It is important that positive breastfeeding messages are used in: i participant orientation programs and materials i printed and audiovisual materials for professional audiences i printed, audiovisual, and display materials for potential clients
Rationale: Including positive breastfeeding messages promotes breastfeeding as the preferred infant feeding choice and reinforces WIC's position on breastfeeding.
GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.
Suggestions for Implementation
1. It is important that evaluation include measures of incidence and duration such as: i incorporation of data collection into current WIC systems i periodic sample surveys of program participants i Centers for Disease Control and Prevention surveillance systems i state surveillance systems i birth certificate information
Rationale: Since few data are available, data collection will help identify and direct further breastfeeding promotion efforts for this population. Assessment of successful strategies will help agencies measure progress toward meeting the health objectives for the nation.
2. If more in-depth information on the incidence and duration of breastfeeding is desired, it is important that information be collected on at least the following categories: i exclusive breastfeeding i patterns of combined breastfeeding and formula feeding, e.g.: i mostly breastfeeding i equal parts breastfeeding and formula feeding i mostly formula feeding i exclusive formula feeding
Rationale: Collecting data on breastfeeding patterns gives a better picture of the WIC population's infant feeding practices. This will help states better focus their breastfeeding promotion activities.

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Attachment BF-4 (cont'd)

3. It is important that questions regarding breastfeeding attitudes, infant feeding decisions, and the WIC program's breastfeeding support activities are included in the annual participant survey.
Rationale: Collecting data on breastfeeding attitudes, infant feeding practices and WIC-related promotion activities about breastfeeding assists state and local agencies design more effective breastfeeding promotion program components.
4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as: i participant orientation and education materials i policies regarding formula samples and food package tailoring for breastfeeding mothers and infants i clinic environment, including display materials and posters, and visibility of formula supplies i staff interaction with participants regarding the infant feeding decision and breastfeeding support i local agency linkages with other community programs providing services to breastfeeding women i staff training plans
Rationale: Guidelines and policies must be implemented in order to affect breastfeeding initiation and duration rates of WIC participants.
GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.
Suggestions for Implementation
1. It is important that a breastfeeding protocol is established to: i integrate breastfeeding promotion into the continuum of prenatal nutrition education i include an initial assessment of participant knowledge, concerns and attitudes related to breastfeeding i provide breastfeeding education and support sessions to each prenatal participant based on the above assessment i define the roles of all staff in the promotion of breastfeeding i define situations when breastfeeding is contraindicated i establish referral criteria

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Attachment BF-4 (cont'd)

Rationale: Making informed choices regarding the best methods of infant feeding is, in part, dependent on staff's ability and efforts to address women's needs and concerns throughout the prenatal period.
2. It is important to develop a mechanism to incorporate positive peer influence into the prenatal period, such as: i peer counselors i an honor roll of successful breastfeeding WIC participants i an opportunity to watch other WIC participants breastfeed i group-facilitated classes with currently breastfeeding WIC participants talking about their experiences
Rationale: Positive peer influence has been shown to be a factor in a woman's decision to breastfeed.
3. It is important to include the participant's family and friends in breastfeeding education and support sessions.
Rationale: Assistance and emotional support from family and friends are helpful to a woman's initiation and continuation of breastfeeding.
4. It is important to encourage the mother to communicate her decision to breastfeed to appropriate hospital staff and physicians.
Rationale: To overcome potential barriers due to hospital and physician practices, women should be aware of the need to request the services that will facilitate successful breastfeeding, e.g., baby put to the breast soon after delivery.
5. It is important for the local WIC agency to coordinate prenatal breastfeeding education activities with primary care providers by: i discussing WIC's position about breastfeeding as optimal for most women and infants i encouraging the sharing of educational materials between WIC and primary care providers i identifying the breastfeeding promotion and support services available in the community and referring participants as needed
Rationale: Coordinating activities in the community increases the likelihood of women and families receiving consistent messages and information about breastfeeding.
6. It is important that the local WIC agency know the breastfeeding practices of their community hospitals and primary health care providers.

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Attachment BF-4 (cont'd)

Rationale: Local agency WIC staff should be part of the prenatal care team preparing women for their early breastfeeding experiences. Positive breastfeeding practices and policies facilitate successful breastfeeding.
GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.
Suggestions for Implementation
1. It is important that eligible women who meet the definition of breastfeeding (the practice of feeding a mother's breast milk to her infant(s) on the average of at least once a day) be certified to the extent that caseload management permits.
Rationale: Breastfeeding women are among the highest priority groups of WIC participants.
2. It is important that breastfeeding women receive a food package consistent with their nutritional need.
Rationale: Breastfeeding women have the highest nutritional needs of any category of women participants and should receive a food package to meet those needs.
3. It is important that breastfeeding women receive support and assistance in order to maintain or increase breastfeeding.
Rationale: All breastfeeding women, regardless of their breastfeeding pattern, need ongoing support so that they feel positive about their breastfeeding experience.
GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.
Suggestions for Implementation
1. It is important that the use of supplemental formula for breastfed infants be minimized.
Rationale: Support that encourages breastfeeding is more effective than offering more formula than the baby is currently using. Clear support which continues to build confidence includes praise and encouragement for her current level of breastfeeding.

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Attachment BF-4 (cont'd)

2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. If a food instrument must be distributed to enroll the infant, consider printing a positive breastfeeding message on the voucher.
Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.
3. It is important to encourage the issuance of vouchers for powdered formula to breastfeeding mothers who wish to supplement.
Rationale: Powdered formula can be prepared in as small a quantity as needed. However, the minimum amount of the concentrated fluid formula that can be prepared is 26 ounces. This amount must be used within 48 hours, which could encourage more supplementation than originally intended.
4. It is important that breastfeeding women receive information about the potential impact of formula on lactation and breastfeeding before formula is given.
Rationale: Breastfeeding mothers may not fully understand the impact formula supplementation has on breastmilk supply. This is especially important during the first few critical weeks when the milk supply is being established.
5. It is important that formula vouchers or samples be given only when specifically requested.
Rationale: Offering formula to a breastfeeding woman undermines her confidence that she can breastfeed successfully, particularly in the first few weeks. She also may find it difficult to refuse the free formula even though she had not planned to use it.
GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.
Suggestions for Implementation
1. It is important to develop a plan to provide women with access to locally available breastfeeding support programs, making sure support is available early in the postpartum period and throughout lactation to:

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Attachment BF-4 (cont'd)

a. Include professional support, such as management of lactation problems, hotline contacts and telephone counselors
b. include peer support, such as peer counselors and resource mothers
Rationale: Professional support programs assist the mother experiencing lactation problems to resolve questions and problems with lactation management. Peer support programs use individuals who have successfully breastfed an infant and who express a positive, enthusiastic viewpoint of breastfeeding.
2. It is important to provide or identify education and support for breastfeeding women in special situations. Consider: a. mothers returning to paid employment or school; mothers separated from their infants due to hospitalization or illness; mothers of multiples; infants with special needs b. support program at times in keeping with the mother's schedule
Rationale: Breastfeeding mothers who are separated from their infants need support programs which include situation-specific information and support.
3. It is important that postpartum contacts with breastfeeding women provide positive reinforcement for the continuation of breastfeeding. Consider: a. using appropriate posters and messages placed in the clinic waiting and nutrition education areas b. including a special breastfeeding message, on vouchers, encouraging the continuation of breastfeeding
Rationale: Encouragement from professional staff and peers can provide motivation to succeed at breastfeeding.
4. It is important to coordinate breastfeeding support with other health care programs and providers, such as: a. Maternal and Child Health b. Family Planning c. hospitals d. Indian Health Service e. community health providers
Rationale: Collaborative relationships result in consistent messages supporting breastfeeding, more efficient services and decreased lactation problems; and reach a larger number of women. These efforts will have a more far-reaching effect as the incidence of breastfeeding increases.
5. It is important that the state agency develop a protocol or guidelines regarding the

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Attachment BF-4 (cont'd)

distribution of breastfeeding aids, including: a. circumstances when the breastfeeding aid might be provided b. guidelines for participant instruction about using the breastfeeding aid
Rationale: Many women have successful breastfeeding experiences without using breastfeeding aids. Breastfeeding aids can enhance breastfeeding success when their distribution is based on individual need and when instruction about the aid is provided.

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Attachment BF-5

BREASTFEEDING RESOURCES RECOMMENDED BY THE OFFICE OF NUTRITION & WOMEN'S HEALTH UNIT
PAMPHLETS & TEAR SHEETS Childbirth Graphics Ltd., P.O. Box 21207, Waco, TX 76702-1207 www.ChildbirthGraphics.com
i 20 Great Reasons to Breastfeed (English and Spanish) i Breastfeeding: Getting Started in 5 Easy Steps (English and Spanish) i Breastfeeding and Returning to Work i Helpful Hints on Breastfeeding (English and Spanish) i Positions for Breastfeeding i The Diaper Diary Tear Pad i How Long Should I Breastfeed My Baby? Tear Pad
BOOKS AND MANUALS Breastfeeding: A Guide for the Medical Profession, by Ruth Lawrence, C.V. Mosby Co., St. Louis, MO, 2005 edition. Breastfeeding: A Parent's Guide, 8th Edition, by Amy Spangler Amy Spangler/Amy's Babies, Atlanta, GA, 2006; English & Spanish Breastfeeding: Keep It Simple by Amy Spangler Amy Spangler/Amy's Babies, Atlanta, GA, 2006; English & Spanish x Breastfeeding: Your Guide to a Happy, Healthy Baby, by Amy Spangler, Amy's Babies, Atlanta, GA; English, Spanish & Chinese Breastfeeding and Diseases: A Reference Guide by Stephen Buescher, MD and Susan W. Hatcher, RN, BSN, IBCLC; Hale Publishing, Amarillo, TX, 2008 Breastfeeding & Human Lactation, by Jan Riordan and Kathleen Auerbach Jones & Bartlett, Publishers, Boston, MA, 4th Edition, June 2009 The Breastfeeding Answer Book, by La Leche League International La Leche League International, Franklin Park, IL, 2003. Counseling the Nursing Mother: A Reference Handbook for Health Care Providers and Lay Counselors, by Judith Lauwers and Candace Woesner. Avery Publishing Group, New York, NY, 4th Edition, 2005 Clinical Guidelines for the Establishment of Exclusive Breastfeeding,International Lactation Consultants Association, June 2005. Medications and Mothers' Milk, by Thomas Hale, Hale Publishing, Amarillo, TX, 13th Edition, 2008. Nursing Mother's Companion, by Kathleen Huggins Harvard Common Press, Boston, MA, 4th Edition, 1999 Best Medicine: Human Milk in the NICU, by Nancy Wight, MD, Jane Morton, MD and Jae H. Kim, MD, Hale Publishing, Amarillo, TX, 2008 The Pediatric Clinics of North America: Breastfeeding 2001, Part I (The Evidence for

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Attachment BF-5 (cont'd)

BOOKS & MANUALS, (continued)
Breastfeeding) and Part II (The Management of Breastfeeding), W.B. Saunders Company, Philadelphia, PA, 2001. Pocket Guide to Breastfeeding and Human Lactation, Second Edition, by Jan Riordan and Kathleen G. Auerbach, Jones and Bartlett Publishers, Sudbury, MA, 2002. The Womanly Art of Breastfeeding, La Leche League International, Franklin Park, IL, 2004. The Breastfeeding Answer Book, La Leche League International, Franklin Park, IL, 2003. The Breastfeeding Answer Pocket Guide, La Leche League International, Franklin Park, IL, 2005. Continuity of care in Breastfeeding: Best Practaices in the Maternity Setting, by Karin Cadwell, Jones and Bartlett Publishers Ten Steps to Successful Breastfeeding, Second Edition, by Karin Cadwell, Jones & Bartlett Breastfeeding A-Z: Terminology and Telephone Triage, by Karin Cadwell, Jones & Bartlett Impact of Birthing Practices on brestfeeding: Protecting the Mother and Baby Continuum, by Mary Kroeger, Jones & Bartlett
VIDEOTAPES & DVDs Better Breastfeeding:Your Guide to Healthy Start, Injoy Videos, 800-326-2082, Ext. 2, English & Spanish, 2009 Better Breastfeeding: A Guide for Teen Parents, Injoy Videos, 800-326-2082, Ext. 2, English & Spanish, 2009 Better Breastfeeding: PowerPoint Presentation, Injoy Videos, 800-326-2082, Ext. 2, 2009 Breastfeeding Best Practice: Teaching Latch and Early Management, (for staff training,) Injoy Videos, 800-326-2082, Ext. 2, video or DVD Breastfeeding for Working Mothers: Planning, Preparing and Pumping; Injoy Videos, 800326-2082, Ext. 2, English & Spanish, 2009 Breastfeeding: The Why-To, How-To Video or DVD set, VIDA Health Communications, 1998, English & Spanish. (Can be purchased separately.) Clinical Management of Breastfeeding: 2-volume set. VIDA Health Communications Infant Cues: A Feeding Guide, Platypus Media, produced in association with Texas Department of Health,10 minutes, Video/ DVD with English & Spanish subtitles Delivery Self Attachment, Geddes Productions, 2007, DVD with English, Spanish, Chinese, Japanese and French subtitles, 6 minutes Breastfeeding: A Special Relationship, English/Spanish, 24 minutes
TEACHING TOOLS Childbirth Graphics Ltd., P.O. Box 21207, Waco, TX 76702-1207 www.ChildbirthGraphics.com i Breast Model
Breastfeeding Chart Collection, 36 panels with presentation notes, English/Spanish i Baby Model
TELEPHONE INFORMATION SERVICES FOR HEALTH PROFESSIONALS i Georgia Poison Control Center
Grady Memorial Hospital, Atlanta, GA (404) 616-9000 or (800) 282-5846

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Attachment BF-5 (cont'd)

Service Provided: Answers to questions on Drugs and Lactation Charge: There is no cost for this service.
i Breastfeeding and Human Lactation Study Center University of Rochester School of Medicine & Dentistry, Box 777, Rochester, New York, 14642 (585) 275-0088; www.bestfedbabies.org Service Provided: Database to assist with questions about pharmaceutical drugs and breastfeeding. Provides bibliographies on breastfeeding and lactation. Charge: None, beyond cost of telephone call.
The Lactation Program
4600 Hale Parkway Suite 140 Denver, CO 80220 (303) 377-3016 Service Provided: Phone consultation with lactation consultants for difficult breastfeeding questions. Charge: None, beyond cost of telephone call.

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Attachment BF-6

ALLOWABLE AND UNALLOWABLE COSTS OF BREASTFEEDING AIDS USED FOR
THE PROMOTION AND SUPPORT OF BREASTFEEDING
The cost of breastfeeding aids that directly support the initiation and continuation of breastfeeding are allowable WIC nutrition services and administration (NSA) expenses. Such expenses can be applied to the State agency's breastfeeding spending target and/or its overall nutrition education expenditures.
Breastfeeding aids which are allowable NSA costs include: i Breast pumps i Breast shells i Nursing supplementers i Nursing bras i Nursing pads i Costs associated with the purchase and availability of breastfeeding aids through the WIC Program, such as insurance and service fees in providing breast pumps i Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. For example: breast models, breastfeeding aids, posters, videos or DVDs, and dolls to illustrate nursing, etc. i Other items which can be shown to directly support the initiation and continuation of breastfeeding.
UNALLOWABLE COSTS
Breastfeeding aids that do not directly support the initiation and continuation of breastfeeding and are not within the scope of the WIC Program cannot be purchased with NSA funds. Such items include, for example: topical creams, ointments, Vitamin E, other medicinals, foot stools, infant pillows or nursing blouses.

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Attachment BF-7

ISSUES TO CONSIDER WHEN PROVIDING BREAST PUMPS
WIC State agencies are currently making breast pumps available to WIC participants in a variety of ways, including:
a. giving away manual breast pumps or electric pump attachment kits; b. selling manual breast pumps or electric pump attachment kits for a
nominal charge; c. loaning hospital grade electric breast pumps; d. contracting with a third party to provide manual or electric breast pumps
to WIC participants; and e. referring WIC participants to providers who rent breast pumps directly to
them for a fee.
While all of the above options are available to the Georgia WIC Program, the following issues should be considered in reference to each:
Giving Away Breast Pumps
Local agencies may give away breast pumps without any reimbursement from participants. This option applies to inexpensive manual breast pumps, small electric pumps, or electric pump attachment kits which do not represent a significant investment of program resources.
Selling Breast Pumps
Local agencies may provide breast pumps by charging a fee to WIC participants (i.e., the purchase price or a portion of the cost to the WIC Program), to partially or totally offset their cost. Since breast pumps are not a direct program benefit, they are not subject to the legislative requirement that WIC benefits must be provided at no cost to participants. Such a plan must be submitted to the Women's Health Unit for approval. A local agency that sells breast pumps to WIC participants must treat the receipts as an "applicable credit" against expenditures for program costs. As applicable credits, these receipts must be used to offset or reduce charges made to the Federal grant for such cost. Applicable credits against expenditures for program costs are discussed in Office of Management and Budget Circulars A-87, Attachment A, paragraph C.3., and A-122, Attachment A, paragraph A.5.
Loaning Breast Pumps and Liability Issues
Manual breast pumps, attachment kits for electric pumps and small electric or battery operated pumps should not be reused, due to the possibility of cross-contamination from improper sterilization. The possible liability cost is high when compared to the cost for a

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Attachment BF-7 (cont'd)

one-person use of a manual pump. In addition, the small electric/battery-operated pumps are often not durable enough to be used repeatedly and their cost is minimal.
Since hospital grade electric breast pumps represent a significant investment of WIC resources, loaning them is the only option. However, under this option, local agencies that directly purchase breast pumps for loan to participants may incur the financial liability of lost or damaged breast pumps. These pumps should be loaned in combination with some means to insure against loss or damage, such as:
a. establishing procedures to ensure that participants fully understand their rights and responsibilities when signing liability release forms;
b. developing an agreement between the program and the participant which stipulates the participant's responsibility to reimburse the program for the value of a lost or damaged pump;
c. monitoring through periodic visual inspection, frequent inventory counts and records, and telephone check-ins; or
d. limiting pump loans only to special circumstances, e.g., after a minimum duration of breastfeeding or for certain medical conditions; and
e. charging a refundable deposit. This deposit must not present a barrier to the participant that would prevent her from being able to borrow the pump. While a lower deposit is encouraged, it must not exceed $20.00, for a hospital grade pump.
Participants may not be terminated or suspended for unreimbursed loss or damage to loaned pumps. While a financial penalty, if included in the original agreement, could be imposed on a participant for failure to return or damage to a pump, the State WIC Program recommends that this approach not be taken. The resources required to recover the cost of the lost or damaged breast pump could easily exceed the value of the pump itself. Building a relationship of trust with WIC participants may minimize the risk of the participant not fulfilling the obligation to return the pump.
If it provides breast pumps, the WIC Program may also be liable for injury to a WIC participant resulting from improper breast pump use, even when there is a signed release of liability. This is true whether pumps are given, sold, or loaned. All participants provided with breast pumps by the WIC Program must be instructed on safe pump use, including proper cleaning of pump and attachment kits and milk storage guidelines.
Contracting with a Third Party
Local agencies may contract with a third party, such as a breast pump manufacturer, hospital pharmacy, or private lactation consultant, to loan or provide breast pumps to WIC participants. WIC employees must not be affiliated with the third party with whom they

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Attachment BF-7 (cont'd)

are contracting.
A major advantage to contracting with a third party is that it transfers liability for equipment loss or damage from the WIC Program to the third party provider, for example, through a loss or damage waiver or insurance fee.
Referrals
A local agency may opt to refer WIC participants to providers who rent breast pumps directly to participants at a fee, such as breast pump manufacturers, hospital pharmacies, and private lactation consultants. This option avoids the liability and financial issues for the program. However, it is likely to pose a financial barrier to WIC participants. In the Georgia WIC Program, this does not meet the requirement for the provision of support to breastfeeding women.
Medicaid Reimbursement
The cost of manual pump purchase and electric pump rentals are generally not covered as a separate benefit under the Medicaid Program. However, in Georgia, the State Medicaid Program does cover the rental of an electric pump and the price of an attachment kit in some cases. Coverage is based on the mother's Medicaid eligibility and so is limited by the period of time the mother is covered by Medicaid in the postpartum period. In addition, coverage is provided for those cases in which the mother and infant are separated by hospitalization, i.e., premature birth.
The electric breast pump and attachment kit must be obtained by a Medicaid Durable Goods provider. It does not require that the provider give instructions to the client on proper use, maintenance and cleaning of the equipment. In these cases, the local agency staff should provide the necessary information and follow-up to the WIC participant. This includes instruction on safe pump use, including proper cleaning of pump and attachment kits and milk storage guidelines.

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Attachment BF-8

STATUS CHANGE FROM PRENATAL TO BREASTFEEDING AND ASSIGNMENT OF PRIORITY TO BREASTFEEDING MOTHER AND INFANT
I. Status Change from Prenatal (WIC Type "P") to Breastfeeding (WIC Type "B") Without a Subsequent Certification:
When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an update to the system. This should occur as soon as the local agency is made aware of the participant's change in status. A subsequent certification is not required in order to simply change the participant's status, as long as she is less than six (6) weeks postpartum. Note: This action does not exclude the participant from the required subsequent certification, in order to continue on the program past the six weeks postpartum.
Listed below are examples of situations in which the simple status change from Prenatal to Breastfeeding might occur:
i A woman calls the clinic to state she has delivered her infant and is breastfeeding.
i A parent of a newborn breastfeeding infant comes to the clinic to enroll the infant in the program.
i A local agency does in-hospital certification of infants only. i A breastfeeding peer counselor notifies the clinic that a participant has
delivered her infant and is breastfeeding.
Follow the steps listed below to change the status of a prenatal women, prior to her subsequent certification:
A. Change TYPE from P to B, since subsequent certification may not take place until 6 weeks postpartum.

B. Change/add the following: DELIVERY DATE, PREGNANCY OUTCOME, and NUMBER OF WEEKS BREASTFED.

C. Change the following if determined to be appropriate (these are optional changes):
1. PRIORITY. A breastfeeding woman's priority can be upgraded if one or more breastfeeding risk factors are identified. The risk factor(s) must be documented in the participant's health record. (See Attachment BF-8 Section II., "Assignment of Priority to Breastfeeding

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Attachment BF-8 (cont'd)

Dyad," below.)
2. FOOD PACKAGE. If the Competent Professional Authority (CPA) determines that a food package change is needed, assign a new food package. Participants who are exclusively breastfeeding (receiving no infant formula through WIC) should be assigned Food Package W61. If this participant has already picked up the current month's prenatal vouchers, you may print one "P05" and one "A30" voucher for her. These vouchers include the cash value fruit & vegetable voucher and the additional foods which are part of the W61 food package.
II. Assignment of Priority to Breastfeeding Dyad
When a participant's status is changed from Prenatal (P) to Breastfeeding (B), prior to her postpartum certification, it may not be possible to assign the same priority to both mother and infant at this time. Please follow these steps in assigning the priorities: A. When a participant's status is changed from Prenatal (P) to Breastfeeding
(B) through a systems update, her priority may be upgraded if there is appropriate documentation. This is optional, however, and she can maintain her Prenatal priority until the subsequent certification.

B. When a breastfeeding infant is certified for, and enrolled in, the WIC Program prior to its mother being subsequently certified, the infant may be assigned one of the following priorities:
1. If the infant has a risk factor of its own that would result in it's being a Priority I, the infant must be assigned a Priority I.
2. If the infant has only nutritional risk factor 701 (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority II. It may be helpful to "flag" the infant's name/record through an internal tracking system (tickler card, computer, voucher register, etc.) to alert staff to the need to re-evaluate the infant's priority at the mother's postpartum certification.
3. If the infant's mother was assigned a Priority I based on documented postpartum breastfeeding risk factors, assign a Priority I to the infant.
C. When the mother of a breastfeeding infant is certified at a later time than the infant, one of the following actions must be taken:

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Attachment BF-8 (cont'd)

1. If the mother is no longer breastfeeding, she must be assessed as a non-breastfeeding postpartum woman (status is changed from P to N), and she must be assigned the appropriate priority based on the assessment. Her infant retains the priority assigned at its enrollment.
2. If the mother is still breastfeeding, she must be assessed as a breastfeeding woman (status is changed from P to B). The highest priority of either the mother or her infant(s) must be assigned to both the mother and her infant(s). This priority and the supportive risk criteria must be documented in the health record of both the mother and her infant(s).

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Attachment BF-9

KEY FOR ENTERING WEEKS BREASTFED

The number of weeks breastfed must be manually entered when completing paper WIC Assessment/Certification Forms and paper Turnaround Documents for:
i Breastfeeding Women: initial and six-month certification visits i Postpartum, non-breastfeeding women: certification visit i Infants: initial certification and mid-certification nutrition assessment visits i Children: one-year of age certification visit (11 to 16 months of age)

Length of time breastfed must be entered in weeks (two-digit). When the answer to the question "how long have you breastfed this baby/child?" or "how long has this baby/ child been breastfed?" is given in days or months, use the following key to determine appropriate codes:

I. Codes to Enter When Breastfeeding is Given in Days

Convert Days to Weeks

Fewer than 7 days

= 00 weeks

7 - 13 days

= 01 week

14 - 20 days

= 02 weeks

21 - 27 days

= 03 weeks

28 - 34 days

= 04 weeks

35 - 41 days

= 05 weeks

42 - 48 days

= 06 weeks

Source: Georgia WIC Branch ETAD Change Number 08-12b, 2008.

II. Codes to Enter When Breastfeeding is Given in Months

1 month 2 months 3 months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 13 Months 14 Months

= 04 weeks = 08 weeks = 13 weeks = 17 weeks = 22 weeks = 26 weeks = 30 weeks = 35 weeks = 39 weeks = 43 weeks = 48 weeks = 52 weeks = 56 weeks = 61 weeks

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Attachment BF-9 (cont'd)

15 Months

= 65 weeks

16 Months

= 69 weeks

17 Months

= 74 weeks

18 Months

= 78 weeks

19 Months

= 82 weeks

20 Months

= 87 weeks

21 Months

= 91 weeks

22.5 Months + = 98 weeks or more

Source: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Public Health Service. February 2000.

BF-48

GA WIC 2010 PROCEDURES MANUAL

Disaster Plan

TABLE OF CONTENTS
Page I. Introduction ................................................................................................................DP-1
A. Purpose............................................................................................................DP-1 B. Scope ................................................................................................................DP-1
II. Policies .........................................................................................................................DP-2 III. Assessing Impact of Disaster....................................................................................DP-3 IV. Concept of Operation ................................................................................................DP-4
A. General.............................................................................................................DP-4 B. Organization ...................................................................................................DP-4 C. Notification .....................................................................................................DP-6
V. Responsibilities...........................................................................................................DP-6 A. Facilities ...........................................................................................................DP-6 B. Issuance ...........................................................................................................DP-7 C. Certification ....................................................................................................DP-9 D. Nutrition Education Contacts ....................................................................DP-10
VI. Resource Requirements...........................................................................................DP-10 A. Staff Requirements.......................................................................................DP-10 B. Infant Formula..............................................................................................DP-11 C. Food Vouchers..............................................................................................DP-11 D. Transportation ..............................................................................................DP-11 E. Masterfile List ...............................................................................................DP-11
VII. Types of Disasters ....................................................................................................DP-11 VIII. Division Mutual Aid Agreement...........................................................................DP-12 IX. Department Disaster Plan.......................................................................................DP-12

Attachments: DP-1 Staff Availability Form ............................................................................................DP-13

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GA WIC 2010 PROCEDURES MANUAL

Date

Time Call Received

District/Unit Clinic

Attachment DP-1

Staff Availability

Staff Name

Staff Telephone

Return to Return to Work Date Work Time

Closure of Issue

DP-13

GA WIC 2010 PROCEDURES MANUAL

Attachment DP-2

Disaster Personnel Time Tracking Form
Summarize incident related activities:

Affected district/County(ies): Federal Disaster Declaration:

Name/SSN

Dates

Location Deployed District/Unit/Clinic

Total Hours

Total Form completed by: Date
Retain to document future federal disaster relief claims
DP-14

GA WIC 2010 PROCEDURES MANUAL

Communications Log

Date

Time

Name of Communicator

Message

Person Receiving Communication

Action Taken

Attachment DP-3

Lead Person

Closure of Issue

DP-15

GA WIC 2010 PROCEDURES MANUAL
AMERICAN RED CROSS LISTING

Attachment DP-4

CHAPTER
Albany Cluster I Coverage: Clay, Dougherty, Lee, Randolph, Terrell

AMERICAN RED CROSS CONTACT
500 Pine Avenue Albany, GA 31701 (912) 436-4845 Fax:(912) 434-9610 arcalbany@isoa.net

CHAPTER
Chatsworth Murray County Chapter

AMERICAN RED CROSS CONTACT
P.O. Box 1301 Chatsworth, Georgia 30705-2535 (706) 695-7605 Fax: (706) 695-6277 Tommy Chapion

Americus Cluster V Coverage: Sumter
Athens East Georgia Chapter

1309 Oglethorpe Americus, GA 31709 (912) 924-2026 Fax:(912) 931-0811 jomason@americus.net
490 Pulaski Street Athens, Georgia 30601 (706) 353-1645 Fax: (706) 353-4701 Redcross1297@home.com

Dalton Dalton Whitfield County Chapter
Dublin Magnolia Midlands Chapter

1101 S Thorton Avenue Dalton, Georgia 30720-7874 (706) 278-5144 Fax: (706) 272-3162 daltnarc@alltel.net
505 Bellevue Avenue Dublin, Georgia 31021 (912) 275-1754 Fax: (912) 275-0601 dlarc@nlamerica.com

Atlanta Metropolitan Atlanta Chapter Cluster VIII Coverage: Fulton, DeKalb, Gwinnett, Cobb, Cherokee, Paulding, Fayette, Butts, Henry, Clayton, Douglas, Rockdale
Augusta Cluster II Coverage: Burke, Columbia, Glascock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro, Warren, Wilkes

1955 Monroe Drive, NE Atlanta, Georgia 30324-4828 (404) 876-3302 Fax: (404) 575-3080 mferguson@arcatl.org
1322 Ellis Street Augusta, GA 30901 (706) 724-8481 Fax: (706) 724-8485 augustag@crossnet.org

Fort Benning/Martin Army Hospital

Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706) 545-5194 Fax: (706) 545-5118

Brunswick Glynn County Chapter

207 Rose Drive Brunswick, Georgia 31520-4243 (912) 265-1695 Fax: (912) 261-1443 glynnredcross@thebest.net

Cartersville Bartow County Chapter

320 West Cherokee Avenue Cartersville, Georgia 30120-3105 (770) 382-0981 Fax: (770) 606-1600 arcbartow@crossnet..org

Gainesville Northeast Georgia Chapter

311 Jesee Jewell parkway, Suite 102B Gainesville, Georgia 30501 (770) 532-8453 Fax: (770) 287-1236 chapter@negaredcross.org

Fort Gordon Dwight D. Eisenhower Army Medical Center

Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 (706) 791-3169/6341 After Hours:(706) 791-4517 Fax:(706) 790-4822

Gordon County Cluster VII Coverge: Gordon

Mary Thomas P.O. Box 342 Calhoun, GA 30703-0342 (706) 629-4510

Griffin Griffin Chapter Cluster VIII Coverage: Spalding

222 Meriwether Street Griffin, Georgia 30223 (770) 227-3145 Fax: (770) 227-9932 arcgriffin@aol.com

Houston-Middle Georgia Cluster VI Coverage: Bleckley, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox

Sam Register 346 Corder Warner Robbins, GA 31088 (912) 923-6332 Fax:(912) 922-8858

DP-16

GA WIC 2010 PROCEDURES MANUAL

Attachment DP-4 (cont'd)

AMERICAN RED CROSS LISTING

CHAPTER
LaGrange Troup County Valley Area Chapter

AMERICAN RED CROSS CONTACT
234 Main Street LaGrange, Georgia 30240-3220 (706) 884-5818 Fax: (706) 882-4364 lagrangeredcross@mindspring.com

Lyons Toombs County Chapter

P.O. Box 49 Lyons, Georgia 30436 (912) 526-3150 Fax: (912) 526-3150 toombsrc@bellsouth.net

Macon Central Georgia Chapter

195 Holt Avenue Macon, Georgia 31201-1224 (478) 743-8671 Fax: (478) 743-7530 bforget@centralga-redcross.org

Milledgeville Oconee Valley Chapter

1131 North Jefferson Street, NE Milledgeville, Georgia 31059-0516 (478) 452-2675 Fax: (478) 451-5376 ovrc@alltel.net

Monroe Walton county Chapter

404 East Church Street Monroe, Georgia 30655-9611 (770) 267-3534 Fax: (770) 207-4338 eshedd@crossnet.org

Moultrie Colquitt County Chapter

1220 S. Main Street Moultrie, Georgia 31768-0000 (912) 985-6924 Fax: (912) 890-2244 cocoarc@planttel.net

Newnan Coweta County Chapter of the America Red Cross

770 Greison Trail, Suite G Newnan, Georgia 30263-0000 (770) 253-2056 Fax: (770) 253-0167 cowetardcross@west.ga.net

Rome Rome-Floyd County chapter

112 John Maddox Drive, NW Rome, Georgia 30165-2733 (706) 291-6648 Fax: (706) 235-2842 arcromega@aol.com

CHAPTER
Savannah Savannah Chapter

AMERICAN RED CROSS CONTACT
422 Habersham Street Savannah, Georgia 31401-4737 (912) 651-9900 Fax: (912) 651-5316 chapter@savannahredcross.org

Statesboro Bulloch County Chapter

515 Denmark Street, Suite 1000 Statesboro, Georgia 30459 (912) 764-4468 Fax: (912) 489-1328 redcross@bulloch.com

Thomaston Upson County Chapter

1998 C Hwy 19 North Thomaston, Georgia 30286-3612 (706) 647-3023 Fax: (706) 647-1260 ucredcross@chapter.net

Tifton Tift County Chapter

420 Dixie Avenue Tifton, Georgia 31794 (229) 382-3133 Fax: (229) 387-7700 tiftarc@friendlycity.net

Valdosta Valdosta County Chapter

527 N. Patterson St., 2nd Floor Valdosta, Georgia 31601-0000 (229) 242-7404 Fax: (229) 219-0469 redcross@surfsouth.com

Warner Robins Houston-Middle Georgia Chapter

346 Corder Road Warner Robins, Georgia 31088-3610 (478) 923-6332 Fax: (478) 922-8858 office@redcrosshmga.org

Waycross Southeast Georgia chapter

610 Elizabeth Street Waycross, Georgia 31501 (912) 283-7846 Fax: (912) 261-1443 segaarc@almatel.net

DP-17

GA WIC 2010 PROCEDURES MANUAL

Attachment DP-5A

PAGE OF
DISASTER DAILY WORK ACTIVITY LOG

DATE:

/ /

NAME: DISTRICT:

OFFICE:

SSN:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to : PM BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to : PM BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to : PM BLDG:

OTHER:

SIGNATURE:

DATE:

Note: MUST ATTACH TO DISASTER EMPLOYEE LOG.

RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS

DP-18

GA WIC 2010 PROCEDURES MANUAL

Attachment DP-5B

DISASTER PROJECTIONS AND PLANNING ASSUMPTIONS

DP-19

GA WIC 2010 PROCEDURES MANUAL

Attachment DP-6

MEMORANDUM OF UNDERSTANDING BETWEEN THE
GEORGIA DEPARTMENT OF COMMUNITY HEALTH AND
THE AMERICAN NATIONAL RED CROSS
I. Purpose
The purpose of this Memorandum of Understanding (MOU) is to establish a working relationship between The American National Red Cross (Hereinafter referred to as the American Red Cross) and the Georgia Department of Community Health (Hereinafter referred to as DCH) in preparing for and responding to disaster relief situations at all levels. This MOU provides the broad framework for cooperation between the two organizations in rendering assistance and service to victims of disaster, as well as other services for which cooperation may be mutually beneficial. The goals of the Georgia Department of Community Health and of the American Red Cross are to ensure that services to disaster victims are coordinated and not duplicated and that no person needing assistance will go un-served.

II. Concept of Operations
Each party to this MOU is a separate and independent organization. As such, each organization retains its own identity in providing service, and each organization is responsible for establishing its own policies and financing its own activities.

III. Definition of Disaster
A disaster is a threatening or occurring event of such destructive magnitude and force as to dislocate people, separate family members, damage or destroy homes, and injure or kill people. A disaster produces a range and level of immediate suffering and basic human needs that cannot be promptly or adequately addressed by the affected people, and impedes them from initiating and proceeding with their recovery efforts.
Natural disasters include floods, tornadoes, hurricanes, typhoons, winter storms, tsunamis, hail storms, wildfires, wind storms, epidemics, and earthquakes. Humancaused disasters whether intentional or unintentional-- include residential fires, building collapses, transportation accidents, hazardous materials releases, explosions, and domestic acts of terrorism (American Red Cross Foundations of Disaster Services Series, July 2003).

The complete agreement is available upon request from the Policy Section.

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Department Disaster Plan
ESF#6
DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY AND CHILDREN SERVICES MASS CARE AND SHELTER STANDING OPERATING PROCEDURES (August 1995)
The Department of Human Services/Division of Family and Children and Services, by executive Order of the Governor, will support any emergency of disaster as directed: Emergency Management Act of 1981, O.C.G.A. 38.3.1.

I. Purpose
1. The purpose of these procedures is to provide the basis for a comprehensive emergency management program that will enable the designated staff to respond quickly and effectively to an emergency or disaster.
2. Emergency management coupled with disaster preparedness is designed to minimize loss of life and property in an affected area.

II. General
The Department of Human Services /Division of Family and Children Services (DFCS) has been designated primary responsibility for (1) coordinating mass and shelter services, (2) administering the Individual and Family Grant (IFG) Program and (3) administering and issuing disaster food stamps in the implementation of the State's overall emergency response plan. DFCS will:
A. Identify mass care and shelter facilities with support from Emergency Management directors and staff of the Division of Public Health, the American Red Cross, and other public and private agencies assigned support roles in this function.
B. Administer and implement the Individual and Family Grant (IFG) Program in the event of a major federal disaster is declared by the President to assist individuals and families who, as a result of a catastrophic occurrence, are unable to meet disaster-related expenses or

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serious needs.
C. Distribute USDA food stamps when the disaster results in individuals and families being unable to meet their food and nutrition needs. This requires the approval of the USDA Secretary on a county by county basis.
D. Cooperate with state/local emergency management teams and assist with duties and responsibilities at the state and community levels as set forth in emergency operation plans.

III. Local Responsibilities
A. Pre-disaster mass care planning
Develop and maintain current listing of facilities that will be available and suitable to provide mass care within each county. This included facilities that would host evacuees from at risk Counties and facilities to meet local shelter needs.
Mass Care encompasses shelter, feedings and emergency first aid. Red Cross with the Assistance of Public Health usually administers the emergency first aid within the first 48 hours of an emergency or disaster.
B. Coordinate local mass care and shelters
At the request of the local Emergency Management director operationalize mass care shelter in coordination with the American Red Cross (ARC) and local community agencies or group with which memorandums of understanding have been developed. The American Red Cross will assume primary responsibility for implementing the mass care and shelter function at ARC-approved sites. DFCS may be needed to staff sites at the onset of their openings for the first 48 hours.
C. Staff the ARC Service Center
Local DFCS staffs help provide information and referral services to disaster victims, provide information regarding individuals within the affected area to family members outside of the affected area and distribute emergency relief items. These services may be provided at a service center established by ARC in the affected community.

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D. Staff the Disaster Assistance Center (DAC)
Provide at least one staff person from the affected area to provide information and referral services at the Georgia Telephone Registration Assistant Center (GTAC) established by GEMA or Disaster Assistance Center (DAC) Established by the Federal Emergency Management Agency (FEMA).
E. Disaster Food Stamp Program
Gather data required to apply for the Disaster Food Stamp program or to request waivers to regular State Food Stamp Program. After the USDA Secretary grants the disaster program and or waivers, DFCS will manage and staff the certification for and issuance of food stamps to eligible individuals and families of a disaster.
F. Grievances
As provided for in applicable DFCS procedures, inform individuals and families of their rights to appeal actions taken by the agency. The Commissioner's Office of Policy and Governmental Services Office, Legal Services office to the Office of State Administrative Hearing, will forward individual grievances.
G. Reports
Provide requested information and status reports to The Department of Community Health Emergency Manager for submission to GEMA and in turn, FEMA as well as designated others. All local reports are submitted through the State Office of the Division of Family and Children Services.

IV. Procedures
A. The GEMA Director or designee will notify DCH of a disaster. The DCH Emergency Crisis Team Manager will provide guidance and support to the DFCS Emergency Management Coordinator to help local DFCS staff meet the "responsibilities in Section III of this document".
B. Staff ARC-approved shelters for not more than 48 hours when requested by ARC.

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C. DFCS will offer support to American Red Cross in the delivery of services at the ARC Service Center(s).
D. In the event of a Presidentially declared disaster, FEMA may open a DAC in the affected area. FEMA will announce Hotline (1-800) tale-registration number and take applications for the IFG program by telephone. FEMA will also provide referral service information to callers.
E. DHS/DFCS will execute the assigned roles as required to assist the affected community area(s).
F. State and county DFCS staff will participate in emergency management training and exercise.
G. Each county DFCS director or designee will participate in the development of the local Emergency Management Plan. The local team will review the pan annually and update it as new or changed resources or procedures are identified.
H. Each county DFCS director or designee will take lead responsibility for developing suitable locations for providing mass care in conjunction with the local County Emergency Manager and American Red Cross.
Potential sites are evaluated by ARC, Public Health environmentalist and Rehabilitation Service community service specialists. A shelter requires Public Health approval. ARC approval is desirable, but is not required where Chapters are not available.
If the site is not approved by ARC but is approved by a Public Health environmentalist, the county director will develop a memorandum of understanding with the owner or other appropriate person(s) to use the facility for mass care. The facility arranges for staff and food, which may be provided by a volunteer group at the facility. (For example, a church recreation hall may serve as a shelter. Church Members or a community volunteer group may provide staff end meals.

V. State Responsibilities
A. The DCH Emergency Management Crisis Team Manager is the official liaison with GEMA and upon GEMA request with FEMA and coordinates services between the divisions of the Department.

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B. The DCH office of Financial Services, in coordination with DFCS Planning, Budgeting and Reporting staff, manages the draw down of Federal funds foe disasters and the issuance of the IEG benefits, and prepares final fiscal figures for closing the IFG Program.
C. DFCS Emergency Management Coordinator staffs and oversees all disaster planning, mitigation, response and recovery efforts and programs within the Division, and works closely with the DCH Emergency Management Crisis Team Manager.
D. The DFCS Disaster Recovery and Mitigation Unit Manager coordinates DFCS service delivery at the GTAC and DAC with affected local county directors; oversees submits requires reports in a timely manner; supervises unit staff and-services as needed as liaison to local partner agencies; directs timely annual revisions to the State IFG Plan; and defines the expectations of staff and development internal procedure for accomplishing the goals of the unit.
E. The DFCS Emergency Management Coordinator and the DFCS Disaster Recovery and Mitigation Unit Manage completes closure of Program. Final reports are submitted through the DCH Emergency Management Crisis Team Manager to the GEMA Executive Director for close-out with FEMA.
F. Final reports of the Disaster Food Stamp Program are submitted the USDA Food and Consumer Service with copier to the DCH Emergency Crisis Team manager for GEMA Executive Director.

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