Georgia WIC program manual fiscal year 1996 [1996]

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61
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TABLE OF CONTENTS

I. Purpose ...

II. Scope
m. References

IV. Prior Approval

.

V Policy Memos

.

VI. Sections

.

A. Introduction (IN)

B. Certification (CT)

C. Rights and Obligations (RO) ....

D. Administrative (AD)

E. Vendor (VN) ..

F. Food Package (FP) .

G. Nutrition Education (NE)

H. Speciai Population (SP) .

I. Outreach (OR)

.

J. Food Delivery (FD) .

K. Quality Improvement (QI) ...

L.
Ii Ii

VII. Administration

.

A. Food and Nutrition Service (FNS/USDA) .

B. State Agency

.

VITI. Addresses

.

A. Local Agencies

.

Attachments:

IN-I Local WIC Agencies

.

IN-I IN-I IN-I IN-I IN-I IN-2 IN-2
!lMs~
IN-3 IN-3 IN-3 IN-4 IN-4 IN-4 IN-4 IN-5
IN-5
IN-6 IN-6
IN-6

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ICjqk, GA WIC PROGRAM MANUAL FY '96
I. PURPOSE
The purpose of the Georgia WIC Program Procedures Manual is to provide local agency staffwith 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.
II. SCOPE
The information in the Georgia WIC Program Procedures Manual applies to all Department ofHuman Resource (DHR) agencies, including district health units and non-DHR agencies that contract with DHR to administer and operate a WIC Program. The ~Ol::gia WIC Program encourages coordination ofWIC 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).
ill. 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 (September 1990) 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 ofsuch requests include local agency assessment/certification forms, time studies, purchasing of ADP equipment, etc.
V. POLICY MEMOS
Georgia WIC policy memos, distributed throughout the year, reflect current policy in the Georgia WIC Program. These policies must be kept at the district and clinic levels, wherever there is a Procedures Manual. Policy memos must be accessible to all staffwho work with the WIC Program. They must be made available to State WIC Office staff during on-site monitoring visits. During the fourth quarter of each year, the Procedures Manual will be completely revised and reprinted and all policy memos from the year will be incorporated into the manual.

GA WIC PROGRAM MANUAL FY '96
VI. SECTIONS
The Georgia WIC Program Procedures Manual is divided into It~~~@l!ii~!~fj sections which
are described as follows:
A. Introduction (IN) Section includes:
Purpose ofthe Procedures Manual Scope of Content in Manual References Prior Approval Requests Sections (outline) Administration ofProgram Addresses (Local and State)
B. Certification (CT) Section includes:
Eligibility Requirements Initial Application Processing Standards Participant Identification
i;!;jii~ilii~'~jilK~f._tl~;1
Nutritional Risk Determination Nutritional Risk Criteria Nutritional Risk Priority System Changes Within A Valid Certification Period Certification Periods Infant Mid-Certification Nutrition

Waiting List Notification Requirements Certified Waiting List Ineligibility Procedures VOC Cards Transfer of Certification Correcting Mistakes Georgia WIC Resource Referral Guide Retroactive Benefits and Reimbursements WIC Volunteers and Confidentiality
IN -2

GA WIC PROGRAM MANUAL FY '96

Program Participation



No Smoking Policy in Local WIC Clinics



C. Rights and Obligations (RO) Section includes:

Rights and Obligations

Nondiscrimination Clause

Public Notification

Civil Rights

Fair Hearing Procedures - Participants and Migrants

Ad . .


Agency

D. Administrative (AD) Section includes:

Section I

Agreement with State Agency Financial Procedures Administrative Cost Categories Shared Costs Time Studies Purchasing Procedures Allocation ofFunds Food Cost Projection Report Program Income
Section II

Retention ofRecords WIC Acronym & Logo Lobbying Restrictions
E. Vendor (VN) Section includes:

Vendor Coordinator Enrollment of New Vendors Vendor Stamp

IN -3

GA WIC PROGRAM MANUAL FY '96

F. Food Package (FP) Section includes:

Authorization of Foods Prescribing Foods - General Infants ChildrenIWomen with Special Dietary Needs Children 1-5 Pregnant and Breastfeeding Women

G. Nutrition Education (NE) Section includes:

Purpose, Definition, Goals of Nutrition Education

State Agency Nutrition Staff and Responsibilities

Local

bilities

H. Special Population (SP) Section includes:

B_ _ Services for Seasonal and Migrant Farmworkers

Services for

~.i:&III~iii~.I!Bi.~

Services for other Special Populations

L Outreach (OR) Section includes:

General Information about Outreach

IN -4

GA WIC PROGRAM MANUAL FY '96
Methods of Outreach Agencies to Contact for Outreach Public Notification Outreach During aWaiting List PIoilfam Costs
!I~~
J. Food Delivery (FD) Section includes:
General Information Types of Vouchers Voucher Issuance - General Computer Printed Voucher Manual Vouchers Georgia WIe Program Identification (ill) Card Proxies Mailing/Delivery ofWIC Vouchers Voided Vouchers

Replacement of Vouchers Automated Manual Voucher System Automated Manual Voucher System Equipment
.. Establish New Clinic/Clinic Changes
K. Quality Improvement (QI) Section includes:
Monitoring
: .~.'iiIIEI~.~:I.liti
Guidelines for Investigating Employee Abuse Procedures to Request an Employee Investigation Vendor Compliance Investigation Compliance Investigation Food Purchases Disqualified VendorlParticipant Lost/Stolen or Destroyed Vouchers
IN - 5

GA WIC PROGRAM MANUAL FY '96

L. Monitoring (MO) Section includes: State Agency Monitoring Quality Assurance Self-Reviews Technical Assistance Local Agency Monitoring Tool
VIT. ADMINISTRATION A. Food and Nutrition Services (FNS)/USDA FNS/uSDA administers the Program nationwide and provides grants to state health agencies. B. State Agency In Georgia, the Department of Human Resources, 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, Inc. and Grady Maternal and Infant Care Project, contract with DHR to administer and operate the WIC Program.
IN - 6

GA WIC PROGRAM MANUAL FY '96
VITI. ADDRESSES
A. Local Agencies
Attachment IN-I contains a listing onocal agency addresses, telephone numbers, and the area served by each agency.
B. State Agencv
For technical assistance regarding all areas, except nutrition-related topics, contact the State WIC Office.
Georgia Department of Human Resources Division of Public Health Family Health Section State WIC Office Two Peachtree Street, N.E. 8th Floor Atlanta, Georgia 30303 (404) 657-2900 or GIST 294-2900 Hotline 1-800-228-9173 FAX (404) 657-2910
For technical assistance regarding nutrition-related topics, contact the Office of Nutrition.
Georgia Department ofHuman Resources Division of Public Health Family Health Section Office of Nutrition Two Peachtree Street, N.E. 8th Floor Atlanta, Georgia 30303 (404) 657-2884 or GIST 294-2884 FAX (404) 657-2910
IN -7

GA WIC PROGRAM MANUAL FY '96 IN - 8

GA WIC PROGRAM MANUAL FY '96

LOCAL WIC AGENCIES

DISTRICT/ADDRESS

COUNTIES SERVED

District 1. Unit 1 (Rome)

Gary Marcum Program Manager Rosemarie Newman WIC Program Coordinator Coosa Valley Health District NW GA Regional Hospital 1305 Redmond Road Rome, GA 30161 (706) 295-6661/GIST 231-6661

Dade, Walker, Catoosa, Polk, Chattooga, Gordon, Floyd, Bartow, Paulding,Haralson

District 1. Unit 2 (Dalton)

Joy Benson, M.D. District Health Director VACANT, Program Manager Sandy Akins WIC Program Coordinator Northwest Health District Bry-Man's Plaza North III Bryant Crossing SuiteAA Dalton, GA 30720 (706) 272-2342/GIST 234-2342

Whitfield, Murray, Gilmer, Fannin, Pickens, Cherokee

Attachment IN-I #ofWIC CLINIC SITES
13
7

IN - 9

GA WIC PROGRAM MANUAL FY '96

DISTRICT/ADDRESS

COUNTIES SERVED

District 2 (Gainesville)

Melody A. Stancil, M.D. ctor
Deputy Program Director Jean Mejorado WIC Program Coordinator North Health District District Health Office P.O. Box 1295 Gainesville, GA 30503 1131 Vine Street Gainesville, GA 30501 (404) 535-5743/GIST 261-5743

Banks, Dawson, Forsyth, Franklin, Habersham, Hall, Hart, Lumpkin, Rabun, Towns, Stephens, Union, White

District 3. Unit 1 (Cobb)

Virginia Galvin, M.D. District Health Director Frances Crutcher Program Manager Beverly Demetrius WIC Program Coordinator Metro West Health District (CobblDouglas) 1650 County Farm Road Marietta, GA 30060 (404) 514-2389

Cobb, Douglas

District 3. Unit 2 (Fulton)

Michael Green

Acting Health Commissioner

Ecleamus Ricks

Deputy Commissioner of Physical Health

Paulette McCray

Nutrition Services Manager

Fulto

. Dept.

Fulton

Atlanta,GA 30303 (404) 730-4050

IN - 10

Attachment IN-I (cont'd) #ofWIC CLINIC SITES 13
6
25

GA WIC PROGRAM MANUAL FY '96

DISTRICT/ADDRESS

COUNTIES SERVED

District 3. Unit 3 (Clayton)

Carlton W. Sargent, M.D. District Health Director Paula Sherrer Program Manager Kathy Thomas WIC Program Coordinator Clayton County Health District 675 Forest Parkway Forest Park, Georgia 30050 (404) 363-6780

Clayton

District 3. Unit 4 (Gwinnett)

James C. Crutcher, M.D. District Health Director Essie Rowser Program Manager Maxine Moore WIC Program Coordinator GwinnettIRockdalelNewton Counties District Health Office P.O. Box 897 Lawrenceville, GA 30246-0897 197 Crogan Street Lawrenceville, GA 30246 (404) 963-0754

Gwinnett, Rockdale, Newton

District 3. Unit 5 (Dekalb)

Paul J. Wiesner, M.D. District Health Director Alan J. Sievert, M.D., M.P.H., Associate Director for Clinical SelV. Carolyn Wetzel WIC Contact Metro-East Health District (Dekalb) Dekalb Co. Board of Health WIC Program 445WinnWay P.O. Box 987 Decatur, GA 30031 (404) 294-3794

Dekalb

IN -11

Attachment IN-I (cont'd) #ofWIC CLINIC SITES
7
8

GA WIC PROGRAM MANUAL FY '96

Attachment IN-I (cont'd)

DISTRICT/ADDRESS District 4, (LaGrange)

COUNTIES SERVED

#ofWIC CLINIC SITES

Lloyd Hofer, M.D.

Fayette, Heard,

18

District Health Director
il!i~.!

Henry, Butts, Carroll, Coweta,

Lamar, Pike,

Meriwether,

WIC Program Coordinator

Troup,

District Four Health Services

Spalding, Upson

122 Gordon Commercial Dr., Suite A

LaGrange, GA 30240

(706) 845-4035/GIST 290-4035

District 5. Unit 1 (Dublin)

Grady Longino, M.D.

B1eckley, Dodge,

10

District Health Director

Laurens,

Jannell Knight

Montgomery,

Program Manager

Pulaski, Telfair,

Wanda Foskey

Treutlen, Wilcox,

WIC Program Coordinator

Wheeler, Johnson

South Central Health District

2121-B Bellevue Road

Dublin, GA 31021

(912) 275-6545/GIST 359-6545

District 5, Unit 2 (Macon)

Craig S, Lichtenwalner, M.D. Acting, District Health Director Ollie Askew Program Manager Jacquelynn Nelson WIC Program Coordinator 811 Hemlock Street Macon, GA 31201 (912) 751-6118/GIST 321-6118

Hancock, Houston,

16

Jasper, Baldwin,

Bibb, Crawford,

Jones, Monroe,

Peach, Putnam,

Twiggs, Washington,

Wilkinson

IN - 12

GA WIC PROGRAM MANUAL FY '96

DISTRlCT/ADDRESS

COUNTIES SERVED

District 6 (Augusta)

ijli~anager
Frances Wilkinson Coordinator

Burke, Columbia, Emanuel, Glascock, Jefferson, Wilkes, Warren, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro

Attachment IN-I (cont'd)
#ofWIC CLINIC SITES

District 7 (Columbus)
Craig S. Lichtenwalner, M.D. District Health Director
g~t~!nffi.i,I~~~tl
Program Manager Jackie Miller WIC Program Coordinator West al Healtl) District

Harris, Talbot,Dooly,

23

Quitman,Taylor, Marion,

Macon, Crisp, Sumter,

Clay, Schley, Webster,

Randolph, Stewart,

Muscogee,

Chattahoochee

District 8. Unit 1 (Valdosta)

Lynne D. Feldman, M.D.

Ben Hill, Berrien

12

District Health Director

Brooks, Cook,

Russell Paulk

Echols, Irwin, Tift,

Program Manager

Turner, Lanier,

Janet McClure

Lowndes

WIC Program Coordinator

P.O. Box 5147

Valdosta, GA 31603

312 N. Patterson Street

Valdosta, GA 31601

(912) 333-5290/GIST 349-5290

IN -13

GA WIC PROGRAM MANUAL FY '96

Attachment IN-I (cont'd)

DISTRICT/ADDRESS
District 8, Unit 2 (Albany)
~li~*!II~!!;:I1I!
District Health Director Barbara Evans Program Manager Charlotte W, Bedell WIC Program Coordinator Southwest Health District 231 Tift Avenue Albany, Gi\ 31708 (912) 430-4111/GIST 341-4111
District 9, Unit 1 (Savannah)
Stephen King, M,D.District Health Director AI Mungin Program Manager Patricia Jackson WIC Program Coordinator East Health District 1321 Bull Street Savannah, Gi\ 31401 (912) 651-2571/GIST 361-2571
District 9, Unit 2 (Waycross)
Ted Holloway, M,D. District Health Director Sue ScatTe P
WIC Program Coordinator Southeast Health District 11 0 1 Church Street Waycross, Gi\ 31501 WIC Office 1718 Reynolds Street, Suite 100 Waycross, Gi\ 31501 (912) 285-6110/GIST 368-6110

COUNTIES SERVED
Terrell, Lee, Calhoun, Worth, Early, Dougherty, Baker, Grady, Mitchell, Colquitt, Miller, Thomas, Seminole, Decatur
Chatham, Effingham
i\ppling, Atkinson, Bacon, Jeff Davis, Brantley, Ware, Bulloch, Candler, Clinch, Charlton, Evans, Coffee, Wayne, Pierce, Toombs, Tattnall
IN - 14

#OFWIC CLINIC SITES
15
10
23

GA WIC PROGRAM MANUAL FY '96

Attachment IN-I (cont'd)

DISTRICT/ADDRESS District 9. Unit 3 (Brunswick)
B. Brooks Taylor, M.D. District Health Director Billy Griner Program Manager Jo Bishop Manning WIC Program Coordinator Coastal Health District 1609 Newcastle Street Brunswick, GA 31521 (912) 264-3907/GIST 365-7326
District 10 (Athens)
Claude A. Burnett, M.D. District Health Director John McKinley Program Manager Vicky Moody WIC Program Coordinator Northeast Health District 468 North Milledge Ave. Room 101-B Athens, GA 30601-3808 (706) 542-9547/GIST 241-9547
Southside Healthcare. Inc.
Dwight E. Jones, M.D. Director Arthur Williams, M.D. Program Manager Laverne Montgomery WIC Program Coordinator Southside Healthcare, Inc. 1039 Ridge Avenue, S.W. Atlanta, GA 30315 (404) 688-1350, Ext. 244

COUNTIES SERVED
Bryan, Liberty, Long, McIntosh, Camden, Glynn

#OFWIC CLINIC SITES
16

Barrow, Clarke,

15

Elbert, Green,

Jackson, Madison,

Morgan, Oconee,

Walton, Oglethorpe

Portions of Fulton and Dekalb

IN - 15

GA WIC PROGRAM MANUAL FY '96

DISTRICT/ADDRESS

COUNTIES SERVED

Grady Maternal & Infant Care Project

All

Director

Lisa Stillman

Chief Nutritionist

Leigh Ann Fenst

Senior Nutritionist

Maternal & Infant Care Project

Grady Memorial 80 Butler Street

#~~~Il;~~

Atlanta, GA 30335

(404) 616-4932

Attachment IN-I (cont'd) #OFWIC CLINIC SITES
3

IN -16

TABLE OF CONTENTS

I. General

.

.CT-l

II. Eligibility Requirements ..

. . . . . . . . . . . . . . CT-l

A. Category ..

......................

.

CT-l

B. Residency

..... CT-2

C. Income

......... CT-2

D. Nutritional Risk.

.

CT-2

11L Initial Application ..

........ CT-2

IV. Processing Standards

... CT-4

A. Timeframes ..

.

CT-4

B. Walk-In Clinics

...... CT-4

C. Request for Extension

.

.

CT-4

V. Participant Identification .. .

.

A. Procedures

.

B. Proxies

.

C. Adjunctive (Automatic) Eligibility .

D. Definition ofIncome

.

tliJ

F. Verification ofIncome

liIJ Nutritional Risk Determination

A. Required Data . . . . . . . . . . . . . . . . . . . . .

.

B. Referral Data

.

C. Medical Data Date

.

Nutritional Risk Criteria

.

X. Nutritional Risk Priority System

A. General

.

B. Special Considerations

.

C. Specific ....

D. Assignment

. . CT-5
@1!j!~ g;lfl~ . . CT-18

f{

Changes Within a Valid Certification Period

A Women Who Cease Breastfeeding

B. Upgrading a Priority . . . . . . . .

.

Certification Periods

.

Infant Mid-Certification Nutrition Assessment

WIC Assessment/Certification Form - General

A. State WIC Assessment/Certification Form

B. Local Agency WIC Assessment/Certification Form

WIC Assessment/Certification Form - Completion . _

A Front

.

B. Reverse Side

_. _

Waiting List

. . .
. . .
. .
.

B. Procedures for Removal from the Waiting ~ist

-

.

A. Waiting List

_

_

.

B. Disqualification C. Expiration of Certification Period

_ -

. mj;i~

D. Ineligibility

.

E. Proces~ngTUneframes F. Right to a Fair Hearing G. Right to Complain About Vendors

~~~
mil! mllg

H. Program Explanation

liI~~

I. Referrals ..................................................... i&~

[!:

Certified Waiting List

....................................... ~llf~q

A. Ineligible Applicants Without Health Records

.

B. Ineligible Applicants With Health Records

.

Verification of Certification (VOC) Cards

__

.

A. VOC Card Definition

B. Required Data

.

C. Orders ..

D. Inventories
~; II:~t\g~ll!Ii:l'.:'liliil,ii: ii:ilill liII,lli'llllllliEliiiIWlll,:i:l:'I:;il:;: ;:Wii;l:l;il:'lill:lli;illlI!~lf~gil,;i'i

F. Security

.

G. Lost/Stolen/Misplaced VOC Cards

H. Instructions for Use ....

Transfer of Certification

A. VOC Card ...

~i ~,~Qn!)~l!!i il, ii.i:i ii!,i! .;ii';l.ll!llil;;;;;iili],;I:llli.:;'i;'::ili!!!::!,; 'li' II!, Qmf'~~I',l!l

c. Georgia WlC I.D. Card

_

.

~j ::;::;~i~:i:i~i~lii:i;:ii;i:i:i:i~iiii:':i':iii;~ili!i!iii;iiJ:~:iilii:i)ii'i:;i:ii:i~i':i:~:I;i;il:ii:!i:i:;:;:i:i;:i

Correcting Mistakes

.

Georgia WlC Resource Referral Guide

.

Retroactive Benefits and Reimbursements

.

WlC Volunteers and Confidentiality ....

Program Participation

.

Mandatory No-Smoking Policy in Local WlC Clinics

Attachments:

CT-l WlC Assessment/Certification Form - Women

CT-2 WlC Assessment/Certification Form - Infants

.

CT-3 WlC Assessment/Certification Form - Children .

CT-4 Signed Statement ofIncome

CT-5 Verification ofIncome Form

.

CT-6 Data and Documentation Required for WlC

Assessment/Certification - Women

.

Attachments:

CT-7 Data and Documentation Required for WIC

Assessment/Certification - Infants

.

CT-8 Data and Documentation Required for WIC

Assessment/Certification - Children

CT-9 Nutritional Risk Criteria - Pregnant Women ..

CT-IO Nutritional Risk Criteria - Breastfeeding Women

CT-II Nutritional Risk Criteria - Postpartum, Non-Breastfeeding Women

.

CT-I2 Nutritional Risk Criteria - Infants

CT-13 Nutritional Risk Criteria - Children .....

CT-I4 Notice of Termination/Ineligibility/Waiting List Form ..

CT-IS Verification of Certification (VOC) Card

CT-I6 VOC Card Inventory Log (Clinic)

CT-17 VOC Card Inventory ):,-og (Local Agency) CT-I8 Measuring I,-engthlHeightlWeight

.
..

. .
.
IDJ.7~

CT-20 Instructions for Use of Prenatal Weight Grid, Prenatal Weight Gain Grids (Form #3059)

.............. .. ~il1.~

CT-21 Dietary Assessment

CT-22 Instructions for Use of the Growth Charts/Growth Charts

CT-23 Weight for Height Table For Determining WIC Eligibility

CT-24 Physical Signs Indicative or Suggestive ofMalnutrition

CT-25 Reco=ended Daily Servings Chart

CT-26 Inappropriate Food Practices

.

CT-27 Georgia Subsidized Child Care Programs

.

.
11i~~ @tf~fl!1 ~.JJ
@Wili:l 11E'ilm mwlli

CT-28 Georgia WIC Program Referral Form

.

CT-29 Nutritional Risk Priority System

.

CT-30 Non-Participation RatelTechnical Assistance Su=ary Report

.

GA WIC PROCEDURES MANUAL FY '96
1. GENERAL
Certification is the process whereby an individual is evaluated to determine eligibility for the WIC Program. All persons wishing to participate in the WIC Program, except those persons transferring within a valid certification period with proper verification, must have their eligibility determined. If eligible and funds are available, the individual will be enrolled in the Program and provided with supplemental food vouchers. The applicant will be notified oftheir eligibility at the time eligibility is determined. A participant shall be issued vouchers at the time they are notified oftheir eligibility. 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. Ifineligible, the individual is properly notified and is not placed on the Program (See:Bf
Ineligibility Procedures).
Program intake procedures will be coordinated whenever possible with intake procedures for other health services. However, participation in any health service beyond what is necessary for WIC certification cannot be required for participation in the Program.
WIC services must be provided to the applicant/participant at no cost.
IT. ELIGffiILITY 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:
A. Category
To meet this eligibility requirement, an applicant must be:
I. A pregnant woman; OR 2. A postpartum, non-breastfeeding woman within six (6) months of the end of a
pregnancy*; OR 3. A postpartum, breastfeeding woman within twelve (12) 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, abortion, miscarriage, etc. 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 ~Wt., Ineligibility
CT-I

GA WIC PROCEDURES MANUAL FY '96
Procedures). Refer to gim, Women Who Cease Breastfeeding, for procedures
regarding the breastfeeding woman who becomes categorically ineligible.
B. Residency
Applicants must reside within the jurisdiction of the State of Georgia. There is no requirement for length ofresidency. The applicant should apply for WIC benefits in the county in which they reside. However, if the applicant routinely receives health care services at a clinic outside their county ofresidence, they may apply for and receive WIC benefits at the same clinic.
For WIC purposes, residency shall be determined using the applicant's self-declared address.
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 WTe purposes.
Migrant farmworkers are considered "fesidents" of the local agency service area in which they apply for Program benefits. ..:
Homeless refers to a woman infant or child who lack regular or primary nighttime residence, or whose residence is: A public or private operated shelter designated as temporary living and/or sleeping accommodation (including a welfare hotel, shelter for domestic violence victims); a temporary accommodation in a residence of another person; an institution that provides temporary residence for individual intended to be institutionalized.
C. Income
Applicants must have a gross family income at or below 185% of the Federal Poverty Level.
D. Nutritional Risk
Applicants must have an identifiable nutritional risk, as determined through a nutritional risk assessment.
ill. INITIAL APPLICATION
A. Initial contact date is defined as the date the individual first visits the clinic during office hours and requests WIC benefits, orally or in writing. An individual's initial contact date will remain the same uuless there is a break in enrollment. A break in enrollment is defined as missing a certification appointment after the current certification
CT-2

GA WIC PROCEDURES MANUAL FY '96
expires, or terminated and not reinstated during a valid certification period.
B. When an individual first visits the clinic during office hours and specifically requests WIC benefits, orally or in writing, the following items must be recorded:
1. Applicant's Name and Address 2. Status (i.e. pregnant, postpartum, infant, child, migrant) 3. Initial Contact Date (date services were requested in person) 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 1-5 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-l, CT-2, and CT-3), or an appointment book.
C. If the applicant does not reside within the jurisdiction of the State, ineligibility procedures will be followed (see @~f\l}W;, Ineligibility Procedures).
D. An income eligibility determination should be made either prior to giving a clinic appointment 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 !W,f~ Ineligibility Procedures).
E. Employees must never certiJY nor recertifY themselves or their family members (i.e. their
children, spouse, cousins or other blood related persons) nor other persons residing in the same household. In cases where a family member(s) requests certification/recertification, another clinic or health department staff must process the application etc. 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 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.
CT-3

GA WIC PROCEDURES MANUAL FY '96
IV. PROCESSING STANDARDS
A. Timeframes
The period from the time an applicant requests WIC services in person to the time he/she receives services must meet certain processing standards. Processing timeframes begin when the applicant visits the clinic in person, during WIC office hours, to make an oral or written request for Program benefits (initial contact date).
Pregnant women, infants, and members of migrant farmworker families will be notified
_i,!iwtl,i::111 oftheir eligibility or ineligibility within ten (10) calendar days oftheir
for Program benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days of their ~~:~i!m;M~lfor Program benefits.
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 III-B must be documented, even for applicants who receive services the same day they request them.
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 so as 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 from 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.
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GA WIC PROCEDURES MANUAL FY '96
V. PARTICIPANT IDENTIFICATION
Clinic staffwill verifY an applicant/participant's identification during each certification visit. The following are acceptable fonns of identification: valid driver's license, immunization record, Medicaid card, Social Security card, or birth certificate. A Georgia WIC ill card may be used for identification purposes only in the clinic in which it was issued. Clinic staff may personally verifY an applicant/participant's identity only if the staff person clearly knows the individual. Other records which clinic staff consider adequate to establish identity may be used if approved by the WIC Program Coordinator or designated CPA. If a CPA is designated for this purpose, their name must be documented in the form of a written policy. Other records used for identification purposes which have been approved must be documented in the form of a written policy.
VI. INCOME ELIGIBILITY
To be eligible for the WIC Program, an applicant/participant must report a gross annual family income equal to or less than 185% of the Federal Poverty Level. Georgia WIC income guideIiIies are implemented simultaneously with the Medicaid program income guidelines.
A. Procedures
All local agencies must use the following procedures and criteria to determine income eligibility for all WIC Program applicants/participants.
1. Prescreening by Telephone. If an individual calls the clinic inquiring about their income eligibility for the WIC Program, they may be told whether or not they are eligible after stating their family size and gross income. Prescreening for income over the phone is a local agency/clinic option. If an applicant's income is assessed over the phone, the State agency recommends that the clinic maintain documentation. The following should be documented: date of inquiry, applicant's name, family size and gross income, eligibility (yes or no), and staffs initials. This should be kept in log fonn. Their formal application for WIC however, begins when they personally visit the clinic. Income must be assessed again at this time.
2. Confidentiality. Clinic personnel who interview applicants for the WIC Program must determine the family size and income in a confidential manner.
3. Detennining Family Size/lncome Eligibilitv. Family size must be determined first. t~;~;~:i!lki(lj!lmf~ri~~l~~_!i Then, the income for that family must be calculated and compared to the maximum income allowed for that family size (see State Plan Attachment A). Income eligibility should be determined before nutritional risk eligibility, whenever possible.
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GA WIC PROCEDURES MANUAL FY '96
B. Proxies. Income information can only be provided by the applicant or the parent/guardian/caretaker of the applicant. The State requires parents! guardians/caretakers to bring an infant/child in for the initial certification and recommends that they bring the child in for subsequent certifications. However, an authorized proxy may bring a child in for subsequent certification, in restricted situations. Situations where proxies may participate in the subsequent certification of a child include:
a. Parent(s) unable to leave their place of employment; b. Illness ofparent(s); c. Imminent childbirth; and d. Other restricted situations, as approved by the WIC Coordinator.
The proxy must have or be able to provide the following information in order to properly certifY a child:
a. A statement of family size and gross income signed and dated by the child's parent/guardian/caretaker. A form for this purpose has been developed by the State (see Attachment CT-4). Use ofthis form is recommended but is optional.
b. A thorough knowledge of the child's medical history and dietary habits/normal .nutritional intake.
c. The ability to discuss the child's health and diet with the competent professional authority.
NOTE: The knowledge the proxy must have regarding (b) and (c) will be the same as you would expect the parent to have.
All signed statements of family size and gross income from the parent/ guardian/caretaker must be filed in the participant's health record. Proxies are accountable for all activities and obligations related to the WIC Program during the subsequent certification appointment.
C. Adjunctive (Automatic) Eligibility
"Adjunctive" or automatic income eligibility for WIC applicants/participants is mandated for the following individuals:
Recipients of Food Stamps and family members.
Recipients of Aid to Families with Dependent Children (AFDC) and family members.
Recipients ofMedicaid or members offamilies in which a pregnant woman or infant receives Medicaid. This includes Presumptive Eligible Medicaid Recipients.
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GA WIC PROCEDURES MANUAL FY '96

(please refer to E.3 for definition of "family".)

It should be remembered that persons who are a4junctively (automatically) income eligible for WIC must still be categorically eligible and determined to be at medical/nutritional risk in order to qualify for the Program.

Acceptable Proof of Eligibility

Ifa WIC applicant presents acceptable proof of enrollment in the programs listed above, income should not be questioned even if the income has changed from the time of enrollment in Medicaid or Food Stamps to application for WIC.

I. Medicaid: Must present a Medicaid card that is current for the same month certification is performed in order to verifY participation in the Medicaid Program. The "Right From the Start" Medicaid list as well as Presumptive Medicaid Eligibility may also be used. Refer to CT-XIV-B.3.b., "Income Determination", for instructions on documenting Medicaid information.

For WIC certification purposes an infant may use his/her mother's Medicaid number for the first sixty (60) days of life. An infant over sixty (60) days old who comes in for certification must have his/her own Medicaid card and number.

2. Aid for Families with Dependent Children (AFDC): Since all AFDC recipients are enrolled in Medicaid, complete as Medicaid recipient.

Participants who are eligible for AFDC receive a letter of eligibility. However this letter cannot be used as proof of eligibility for WIC because this letter does not indicate an ex:piration date. The Medicaid Card is the only proof of eligibility for AFDC participants seeking WIC certification.

3. Food Stamps: Must present a Notification Letter (with dates of eligibility), or a \ Food Stamp Identification (ill) Card with valid Food Stamp Number and expiration
date.

NOTE:

If a letter ~ijl~~i:~m;ll~liit1l4is presented as proof, a copy must be placed in the record.

4. Verification of income is only necessary as outlined on CT-VI.F..

5. Ifthe applicant does not have proof of enrollment in Medicaid or Food Stamps, you must determine income eligibility using actual income.

D. Definition ofIncome

Income is defined as gross cash income before deductions for income taxes, employee's social security taxes, insurance premiums, bonds, etc.

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GA WIC PROCEDURES MANUAL FY '96
E. Computing Income
1. Current vs. Anmml. Clinic staff; in detennining income eligibility, must consider the income of the family during the past twelve (12) months and 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 in each individual income determination.
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
3. Definition ofFamily/Economic Unit
Family means a group of related or nonrelated individuals who are living together as one economic unit, except that residents of a homeless facility or an institution shall not all be considered as members of a single family.
An emancipated minor is an adolescent (under eighteen [18]) who is legally married or divorced.
Ifan adolescent (under eighteen [18]) is not an emancipated minor and lives at home with her parents, she is considered the responsibility of her parents and is a part of her parent's family.
a. Children Residing with Caretakers. A child is counted in the family size of the parent, guardian, or caretaker 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 sizelhousehold of the grandparent.
b. Foster Child. If the child is a foster child who is living with a family but who remains the legal responsibility of a welfare 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 are considered to be the income of that foster child.
c. Adopted Child. If a child lives with a family who has accepted legal
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GA WIC PROCEDURES MANUAL FY '96
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 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.
f Absent Spouse (excluding military families. See CT-VI.E.3.i.). 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 N (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:
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. AlieoslForeign Students. It is legal for an alien/foreign student and his or her family to receive WIC benefits. Neither the WIC authorizing legislation nor the WIC regulations require citizenship or make aliens categorically ineligible for the WIC Program. State and local agencies do not have the authority to exclude aliens solely on the basis of their alien status. Clinic staff may not inquire directly regarding an applicant's citizenship status. However, such
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GA WIC PROCEDURES MANUAL FY '96
information may incidentally become known during the eligibility determination process, e.g. in connection with inquiries regarding sources offamily income. When this occurs, staff may wish to explain that "It is against WIC Program regulations to furnish this information to the Immigration and Naturalization Service (INS). However, you need to be aware that if INS is alerted you may be subject to deportation." Participation should not be needlessly discouraged, therefore, clinics should not further advise applicants on this subject.
1. Military Families
1. .Military personnel serving overseas or assigned to a military base are considered to be members ofthe 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 ill if the child(ren) and one parent temporarily move in with friends or relatives, choose one of the following options:
(1) Count absent parents and exclude current caregivers. (2) Count children as separate economic unit. The children are considered
as baving their own source of income (e.g., child allotments). When ushi.g this method, Districts must decide whether the income is adequate to sustain the children Ifthe children's income allotments are not adequate, then option I or 3 should be used. (3) Count children as members of caregiver's household. Determine family size and income based on the family the child(ren) is/are living with. Include the children in the family size.
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 ofdivorce, may not be considered part ofthe 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.
4. 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
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GA WIC PROCEDURES MANUAL FY '96
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;
1. Alimony or child support payments;
j. Regular contributions from persons not living in the household;
k. Net royalties;
1. 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.
5. Income Exclusions
a. The value of in-kind housing and other in-kind benefits. An in-kind benefit is anything ofvalue 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 include, but are not limited to:
(1) National School Lunch Act and the School Breakfast Program (2) The Food Stamp Act ofl977 (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 (II) Title IV student financial assistance (see CT-VI.E.3.g.).
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GA WIC PROCEDURES MANUAL FY '96
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. Child care benefits provided under section 402 (g)(1 )(E) ofSocial Security Act, At-Risk Child Care Programs and Child Care and Development Block Grant Programs in Georgia are excluded from the WIC income eligibility process. (See Attachment CT-27 for Georgia Subsidized Child Care Programs).
Non-payment child care benefits are not considered as income. (Attachment CT-27list the "non payment" child care benefit programs operating in Georgia). 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.
6. UnemI;110yment. Applicants from families with adult members who are unemployed shall be eligible based on income during the period of unemployment if the loss of income causes the current rate of income to be less than the income guidelines. Persons who are on leave that they themselves requested (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. Ifa woman is on extended maternity leave [greater than six (6) months], it may be more appropriate to use current income to determine eligibility.
7. Self-Employment. In farnilies where one (1) or more 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 ofgoods 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 offeed, fertilizer, seed and other farming supplies; cash wages
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GA WIC PROCEDURES MANUAL FY '96
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 both farm and non-farm self-employed persons, documentation of depreciation must be obtained 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).

8. Migrant Fannworkers. Income eligibility is valid for instream migrant farmworkers

and their family members for a period of 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 instream area during the agricultural season. Migrant farmworkers

with expired VOC cards are still income eligible if the income determination

occurred during the last 12 months. If the migrant's family income must be

redeterminec\, clinics are encouraged to consider income during the past twelve

months.

.

9. Hardship Conditions. Hardship conditions have been calculated in the Income Poverty Guidelines Chart. Hardship conditions are not to be considered when determining income.

10. Lump Sum Payments

Lump sum payment may be classified in two ways, reimbursement or new money.

Reimbursement payment 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 WlC 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 current income. Rather, the sum payment should be counted as annual income, or be divided by 12 to estimate a monthly income.

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GA WIC PROCEDURES MANUAL FY '96
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 instance treat the lump sum payment in a way that most accurately reflects the economics situation ofthe household.
Examples of such payment include legal or medical settlement that provide reimbursement for lost property and medical expenses as well as compensation for physical or mental injury.
F. Verification ofIncome
The Georgia WIC income screening policy does not require proof of income from applicants. All applicants must be allowed to self-declare their income. This policy applies to State employees and military dependents/personnel as well.
Verification of income is not necessary unless one (1) ofthe following occurs:
1. The person taking the income has a valid reason to believe 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 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.
Procedures for Verification. When a participant's income must be verified, a Verification of Income Form (Attachment CT-5) must be completed. Instructions for Completing the Verification oflncome Form:
1. Date and sign the top of the form.
2. Document the name of the applicant/participant.
3. Document the reason for requesting the verification.
4. NotifY the WIC Coordinator that you are about to verify a participant's income (District option).
5. Inform the participant that you have reason to believe that the income information they gave you at certification may not be correct. Do not give out the name ofthe person who made the complaint Complete the bottom half ofthe form with the date you requested verification, the date they need to submit the verification
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GA WIC PROCEDURES MANUAL FY '96 information by (30 days from the date of the request), and your initials. Detach the bottom halfand give it to the participant in order to obtain income verification. The following are acceptable: a. Pay stubs b. Official statement from the employer, or any responsible person who could verifY the situation if the employer refuses to do so c. Most current tax return d. On-going records (for self-employed only) Fill in the date you requested verification and your initials on the top half of the form for documentation purposes. If the participant fails to bring in the required documentation within thirty (30) days of the day you request it, he/she must be terminated.
6. When the necessary documentation is brought in, document the date it was submitted and attach it (or a copy) to the form.
7. Complete items 4 and 5 on the form. 8. Discuss the information with the participant and request an explanation for any
difference in the income. 9. If the income determined through verification is within WIC income guidelines,
inform the participant that they are still eligible for benefits. Ifthe income determined through verification exceeds the income scale, the person must be terminated immediately. Refer to the Rights and Obligations Section (RO) for procedures regarding claims against participants. 10. Any and all actions taken when verifYing income must be documented in the medical record. This procedure must be consistently implemented throughout each local agency.
m.........R.....M.......E.....i.E...__E.. __ iG_---n- ml-limliiEi1fREtiN-- f-A." iN;ilM!omN
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GA WIC PROCEDURES MANUAL FY '96



NUTRITIONAL RISK DETERMINATION

To be certified for the WIC Program, an applicant/participant must be determined to be at nutritional risk. Nutritional risk is determined through the assessment of required medical data (Iength/height, weight, hematocrit/hemoglobin), dietary information, and the individual's medical history. This data is 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, physician's assistant, or other certified health official that has been trained by the State or local agency.

Applicants for WIC benefits may not under any circumstances be charged for services or tests (i.e. bloodwork; anthropometric measurements, etc.) which are used to determine Program eligibility. Ifthe local agency is not set up to perform such 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. The applicant cannot be required to obtain such data at her own expense.

A. Required Data

1. Women. Attachment CT-6lists 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. Requiring proof ofpregnancy is not a condition of eligibility for the WIC Program. However, if it is not physically apparent that the applicant is pregnant, the local agency may require proof of pregnancy. In this case, she can be given up to sixty (60) days to submit proof of pregnancy.

H such documentation is not provided as requested, the local agency would be justified in terminating 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-7 lists required assessment data and documentation requirements for all infants by age. This data must be collected and documented for

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GA WIC PROCEDURES MANUAL FY '96
each assessment.
3. Children. Attachment CT-8 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
The determination of nutritional risk can be based on referral data submitted by a CPA not on staff at the clinic. Referral data must then be evaluated by a CPA or staff at the clinic. Local agencies should make available to area health care providers referral forms in order to facilitate entry into the WIC Program and the certification process. Local agencies may use the Georgia WIC Referral Form (see Attachment CT-28), or may develop a referral form to meet individual local agency needs. All new and revised forms must be submitted to the Office ofNutrition for approval, prior to implementation. All referral forms must contain, at minimum, the following information:
I. Demographic Data a. Applicant's Name b. Address/Phone Number c. Date of Birth
II. Required Medical Data a. Length/Height b. Weight c. HematocritlHemoglobin d. Date measurements were taken
III. Referral Agency Information a. Signature and Title ofHealth Professional b. Agency Address c. Agency Phone Number
Local agencies must accept referral forms from a non .WIC clinic CPA provided that all of the required minimum referral data/information has been completed properly. The data/information must be documented on official letterhead stationary in the absence of a health department referral form.
As an integral part of outreach efforts, local agencies should provide area health care providers with a current listing of nutritional risk criteria along with definitions and documentation requirements for these.
C. Medical Data Date
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GA WIC PROCEDURES MANUAL FY '96

Medical data required for certification (length/height, weight, and hematocritlhemoglobin) 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 required medical data (length/height, weight, and hematocritlhemoglobin) even if the applicant/participant's eligibility is based on other criteria.

NUTRITIONAL RISK CRITERIA

Nutritional risk criteria are set by the State agency, in accordance with federal rules and regulations. The criteria are based on detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements, other nutritionally related medical conditions, dietary deficiencies that impair or endanger health, or conditions that predispose persons to inadequate nutritional patterns or nutritionally related conditions.

Nutritional risk criteria, risk factor codes, and priority designations used for Georgia WIC Program certification are listed in Attachments CT-9, CT-IO, CT-II, CT-12, and CT-13. The nutritional risk criteria are listed by applicant/participant status at the time of certification. Each criterion is coded using a letter from the alphabet.

The WIC Assessment/Certification Forms utilize a checklist format to document. the

!1l1tEl applicable nutritional risk criteria. Refer to

for information regarding the

completion of the WIC Assessment/Certification Form.

NUTRITIONAL RISK PRIORITY SYSTEM

A. General

Each nutritional risk criterion is assigned a specific priority. Statewide priorities are set in accordance with the following guidelines:

I. PrioritY I: Pregnant women, breastfeeding women, and infants at nutritional need. This need is determined by measuring heightlweight, taking a blood test and medical history.

2. Priority II: Breastfeeding women who do not qualifY under Priority 1, but are breastfeeding Priority 2 infants.

Infants up to six (6) months ofage born to women who were Program participants during their pregnancy.

Infants up to six (6) months of age born to women who were not Program participants during pregnancy but had a nutritional need.

3. Priority ill: Children with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.

Postpartum teenagers who are not breastfeeding.

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GA WIC PROCEDURES MANUAL FY '96

4. Priority IV: Pregnant women, breastfeeding women, and infants with a nutritional need because of poor diet g~(igm~~$!~1'!!!gfiillll!~!~t@S.
5. ~~t~~~ V: Children at nutritional need because of poor diet li~g!~ji~!.1'!!!Im;~iY

6.

VI: Postpartum, non-breastfeeding women with a nutritional need

B. Special Considerations 1.

2. Possibility of Regression. If it has been determined that the only applicable risk criterion is Possibility ofRegression (Z), the priority from the previous certification is retained.

During periods of caseload management when it is necessary to limit the number
of priorities being served or maintain a waiting list, risk criterion "Z", Possibility
of Regression, cannot be used as a reason for certification.

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 1: Priority IV:

A, B, C, D, G, H, I, J, K, L, M, N, 0, P, Q, R, S, T, U X,3

2. Breastfeeding Women

Priority 1: Priority II: Priority IV:

A, B, C, D, G, H, I, J, K, M, N, 0, P, Q, R, V V V,X,3

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GA WIC PROCEDURES MANUAL FY '96 3. Postpartum Non-Breastfeeding Women

Priority III: Priority VI:

G A, B, C, D, H, I, J, K, M, N, 0, P, Q, R, X, 3

4. Infants

Priority I: Priority II: Priority IV:

A, B, C, E, F, I, J, 0, P, V V, W,3 V, X,

5. Children

Priority III: Priority V:

A, B, C, E, F, I, J, Z X, Z, 3

D. Assignment

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

CHANGES WITHIN A VALID CERTIFICATION PERIOD

A. Women Who Cease Breastfeeding

The following procedures must be followed when clinic staff are notified by a woman participant that she is no longer breastfeeding:

1. Ifthe woman is more than six (6) months postpartum, she is categorically ineligible and must be removed from the Program immediately (See CT-XVI.D., Ineligibility Procedures). The termination must be documented in the participant's health record.

2. Ifthe woman is less than six (6) months postpartum, it must be determined whether the woman would qualifY for WIC based on the risk criteria for a postpartum, nonbreastfeeding woman. If there is a nutritional risk reason, the woman's status, priority and food package must be changed. Ifno nutritional risks are evident, new certification information must be collected to determine ifthe woman could 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 on the Turnaround Document (TAD).

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GA WIC PROCEDURES MANUAL FY '96
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 non-breastfeeding woman).
CERTIFICAnON 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 certification and ending when the breastfed infant turns one (I) year of age or when breastfeeding is discontinued, whichever comes first.
Postnartum, Non-Breastfeeding Women: for up to six (6) months from the termination oftheir pregnancy.
Infants (six [6] months of age or younger): until their first birthday.
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 certification and ending with the end of the month in which they reach their fifth birthday.
Vouchers may only be issued to participants who are in a valid certification period. The certification period always begins with the date of certification. In the event a participant becomes categorically ineligible during this time, and the date of termination is before the end ofthe month, eligibility is extended to the end of the month, (See FD-llLE,)
In cases where there is difficulty in scheduling appointments for breastfeeding women, infants, and children only, 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.
; INFANT MID-CERTIFICAnON 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 betweenfive (5) and seven (7) months ofage. To ensure accessibility to quality health care services, the following procedures must be in place:
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GA WIC PROCEDURES MANUAL FY '96

1. The initial certification of the infant less than six (6) months of age will follow the standard procedures. 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 d. recording, summarizing, and evaluating dietary intake e. assessing nutritional risk criteria f assigning the highest priority for which the infant is eligible g. reviewing food package needs 3. The mid-certification nutrition assessment information will be documented in the second column of the Infant WIC Assessment/Certification Form.

4. If; at any time during the one (1) year certification period, the infant's nutritional risk should permit the assignment of a higher priority, the infant's priority should be upgraded to the appropriate priority. An infant must never be assigned a priority lower than the original priority.

1m

5. Program benefits may not be withheld from a participant for failing the midcertification nutrition assessment appointment(s). Missed appointments should be documented in the participant's health record.
WIC ASSESSMENT/CERTIFICATION FORM - GENERAL

A. State WIC Assessment/Certification Form

Certification data for each applicant/participant will be recorded on the form provided by the State agency. The State provides three (3) color-coded forms:

Women Infants Children

-Pink - Blue - Orange

B. Local Agency WIC Assessment/Certification Form

If a local agency/clinic chooses to use other forms and/or documentation procedures in the certification process which are different than 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 who 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.

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GA WIC PROCEDURES MANUAL FY '96
WIC ASSESSMENT/CERTIFICATION FORM - COMPLETION
Each form is two-sided. Both sides must be accurately completed each time an individual is certified. A portion of the required information is common to each form. The following are instructions for completion:
A. Front
I. Identification Infonnation. Applicant's name, birthdate, address, county, telephone number, social security number (optional), ethnic origin, migrant status, clinic number, and parent/guardian/caretaker's name (infants and children only), must be filled in on each form used.
2. Initial Contact Date. The initial contact date must be filled in at each certification, even ifit has not changed. The initial contact date must be accurately documented to ensure that processing standards are being met. Refer to page CT-III. for the definition of "initial contact date. "
3. ITlcome Eligibility. Check "Yes" or "No" to indicate applicant's "income eligibility. Refer to CT-XIV.B.3., "Reverse Side of the Assessment/ Certification Form," for incQme screening information.
4. Medical Data Date. See CT-VII. C. for definition of required medical data. Enter the date medical data was taken for certification purposes. If the anthropometric measurements were taken on a date different from the hematological measurements, the date ofthe anthropometric measurements should be entered in this space. The date of hematological measurements must be documented in the health record.
5. LengthlHeight. Enter the lengthlheight to the nearest eighth of an inch.
6. Weight. Enter the weight in pounds and ounces.
7. HematocritlHemogiobin. Enter the hematocrit and/or the hemoglobin value(s) in the appropriate half ofthe box. Values are to be entered to one decimal place.
8. Nutritional Risk Criteria. Complete each line in this section using the following procedure:
a. Check "Yes" when the nutritional risk criterion is present. b. Check "No" when the criterion is not present. c. Write "N/A" when the risk criterion does not apply or was not assessed.
This section of the form must be completed by a CPA during each certification appointment and at the infant's mid-certification nutrition assessment.
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GA WIC PROCEDURES MANUAL FY '96

9. Eligible for WIC. Check "Yes" when all of the following criteria are met:

a. the applicant resides within the State of Georgia; b. the applicant is income eligible; c. at least one (I) nutritional risk criterion is checked "Yes".

Check "No" when "a" checked "No" (see

from the above list and/or all nutritional risk factors are Ineligibility Procedures).

10. Priority. Enter correct priority (I - VI). Refer to CT-IX.A. for risk factor codes and priorities.

11. Food Package. Enter the appropriate food package code (See Section FP, Food Packages).

12. Services. Enter referrals and/or enrollments to other health services and programs using codes listed on the WIC Assessment/Certification Form. When referrals and/or enrollments are documented elsewhere in the health record, documentation does not have to be duplicated. See Section NE, Nutrition Education, for more information regarding required referr~s.

a. ."Referred To" is used when a person has been given information regarding other health services and programs.

b. "Enrolled In" is used when a person is already utilizing other health services and programs.

13. Today's Date. Enter the date the assessment is completed. 14. Signature!fitle. Enter signature and title (Nutr., R.D., L.D., R.N., M.D., etc.). An
appropriate signature consists of frrst and last name or first initial and last name.

B. Reverse Side (Income Determination)

1. Date. Fill in the date the income screening was completed.

2. Number in Family. Fill in according to CT-VI (A.3).

3. Gross Income/Mo.

a. Food St

c. AFDC Recipients. Complete as Medicaid recipient. CT- 24

GA WIC PROCEDURES MANUAL FY '96 d. Participants not receiving Food Stamps Medicaid or AFDC. Complete according to CT-VI (E).
4. ~tiilRSignature. The staffmember(s) collecting the income/residence/ID data must enter their signature(s). An appropriate signature consists of first and last name or first initial and last name. If the person who collects the income information is different from the person determining residency, each must sign the space. The participant, parent/guardian/caretaker, or proxy must be asked to read (or have read to them ifthey are unable to read) and sign the following statement each time they are certified:
Due to the content ofthis statement, clinic staff must ask the participant to read (or have read to them if they are unable to read) the Rights and Obligations Handout prior to requesting the participant/authorized representative's signature. When a clinic serves any non-English speaking persons, this information must be provided in a language they understand. If the participant/authorized representative is unable to write, he/she will enter his/her mark in lieu of a signature. The staffperson will print the person's name next to the mark and initial the mark to indicate that it has been witnessed. 5. Date. The date must be completed by either the participant/authorized representative or a clinic staff person. WAITING LIST A waiting list is intended to facilitate the placement of the highest priority persons at the earliest opportunity when demand exceeds available funds. Local agencies may not accept telephone requests for placement on the waiting list. Waiting lists do not constitute certification records and are not bound by federal recordkeeping requirements. The State agency requires waiting lists to be retained for a period of one (1) year plus the current year. Local agencies must establish a waiting list in the following situations when:
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GA WIC PROCEDURES MANUAL FY '96
I. The WIC Program, statewide, is spending in excess of 100% of the available food dollars.
When this occurs it will be necessary for the State agency to limit the number of priorities served by each local agency. It is not necessary for local agencies to maintain a waiting list of those individuals whose priorities are not likely to be served statewide. To do so may create "false hopes" for many. However, if an applicant insists on being placed on a waiting list, then he/she should always be placed on the waiting list.
2. The local agency is spending in excess of 100% of their allocated food dollars.
The State agency strives to assure that the same priorities are served statewide. However, there may be periods oftime when a local agency exceeds their allocation and must maintain a waiting list until the State agency can identifY funds for reallocation. All applicants in the priority group(s) not being served by the local agency must be placed on the waiting list.
A Procedures for Maintaining a Waiting List
I. A waiting list shall be maintained of individuals who .qualifY and express an interest in receiving Program benefits. Local agencies are required to establish waiting list(s) by priority. Applicants must be kept in date order, according to the date they were placed on the waiting list. Once a waiting list has been established for any of the above reasons, only applicants who are still eligible in the priority group(s) which is/are being added from the waiting list are enrolled on the Program.
2. To facilitate contacting the applicant when caseload space becomes available, the waiting list must include the following:
a. Date applicant was placed on the waiting list b. Applicant's name c. Applicant's address and telephone number d. Applicant's status (e.g. pregnant, breastfeeding, age of applicant, etc.) e. Applicant's priority
3. All persons must be notified oftheir placement on the waiting list within twenty (20) days of their initial contact date. This notification must be made, in writing, using a Notice of TerminationlIneligibilitylWaiting List Form (see Attachment CT-14).
Procedures for Completing the Notice of Terminationllneligibility/ Waiting List Form:
a. Complete the participant's name and date, i~~I~R~I~l1lQ~'I~" at the top of the form.
b. Sign the form and have the participant/parent/proxy sign the form.
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GA WIC PROCEDURES MANUAL FY '96

c. Complete the information at the bottom ofthe 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.

Those applicants eligible in lower priority groups not being served, who are not put on a waiting list, must be given notice of their status using a Notice of TerminationlIneligIbilityl\Vaiting List Form. Each applicant who is put on a waiting list or denied WIC benefits must be advised of their right to a fair hearing and where to request a fair hearing.

NOTE:

The Notice of TerminationlIneligibilitylWaiting List Form should not specify the length oftime (no specific date) for remaining on a waiting list (See attachment CT-14).

4. Transfers. When a waiting list is in effect, migrants and other transferring participants with a valid Verification of Certification (VOC) card must be placed on the Program regardless of priority.

5. Clinic staff should always explain why placement on a waiting list is necessary and what it means in terms of realistic possibilities of receiving benefits. Referral to other health and social service programs should be made when appropriate.

6. Referral during a Waiting List

As the number of Waiting List applicants increases, the need for referral to other food assistance resources is inevitable. Local agencies must refer waiting list applicants to local Food Assistance Programs or Services. These programs/services include, but are not limited to:

- Food Stamps Program -FoodBank - Food Cooperatives - Churches/Synagogues Food Pantries - Salvation Army - General Assistance Funds

B. Procedures for Removal from the Waiting List

The CPA must ensure that the following procedures are followed when removing persons from the waiting list as caseload expansion is re-established:

1. Ifa waiting list contains transfers, they must be removed from the waiting list first and given WIC benefits. If there is more than one (1) transfer on the waiting list, they must be removed in "date order" with the oldest date removed first.

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GA WIC PROCEDURES MANUAL FY '96
2. After all transfers have been removed from the waiting list, persons will be removed in priority order, highest priority first. Within each priority, persons must be removed in "date order" (i.e. the date they were placed on the waiting list), oldest date first.
3. Only those individuals who are still categorically eligible need to be contacted. All others can be periodically purged from the list.
4. 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.
5. Applicants will be contacted by phone or letter.
~m; NOTIFICATION REOUIREMENTS
The following notifications shall be made, in writing, within the following timeframes:
A. Waiting List. Applicants shall be notified of their placement on a waiting list within twenty (20) days of their initial contact date. Notification will be made using a Notice ofTerminationlIneligibilitylWaiting List Form. A copy ofthis form must be filed in the applicant's health record.
B. 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 (30) days before termination ofthe reason(s) for this action and of the right to a fair hearing. In the event the State Agency mandate that the local agency must suspend or terminate benefits to participants due to a shortage of funds, The Notice of TerminationlIneligibilitylWaiting List Form must be issued to the participant. Homeless and high risk participants will be notified at least lIiiIIt~~~ days before termination. (High risk participants are participants in the following categories: Pregnant Women, Breastfeeding Women, Infants, and Post-Partum Teens). Notification will be made using a Notice ofTermination/IneligibilitylWaiting List Form. A copy of this form must be filed in the individual's health record. This notification does not need to be provided to persons who will be disqualified for failing to pick up vouchers for two consecutive months provided the participant has been given or read the Rights & Obligations Handout.
Persons terminated during a certification period must be provided a list of the participant priority categories. The list must include definitions of each category (See Attachment CT-29). This notice is only applicable when participation must be reduced due to funding shortage.
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GA WIC PROCEDURES MANUAL FY '96
C. Expiration of Certification Period. Each participant will be notified at least (15) days before the expiration of their certification period that certification for the Program is about to expire. Homeless participants will be notified at least (30) days before the expiration of their certification period.

D. Ineligibility. All persons determined to be ineligible for Program benefits on the basis

of residence, income, or nutritional risk will receive a Notice of

Termination/Ine1igibilitylWaiting List Form

states the reason(s) for

ineligibility. A copy of the form will be filed in the individual's health record and/or the

ineligibility file (See Attachment CT-14).

NOTE: Please complete the Fair Hearing Section of the Notice of TerminationlIneligibilitylWaiting list Form.

E. Processing Timeframes. Members ofmigrant farmworker households, pregnant women, and infants will be notified of their eligibility or ineligibility for the Program within ten (10) days oftheir initial contact date. All other applicants will be notified of eligibility within twenty (20) days ofthe initial contact date.
F. Right to a Fair Hearing. Each applicant will be informed of their right to a fair hearing in the following situations:
1. At the time of a claim against an individual for improperly issued benefits. 2. At the time of participation denial or disqualification from the Program.
Notification shall include the method by which a fair hearing may be requested, and that any positions or arguments on behalf of the individual may be presented personally or by a representative such as a relative, friend, legal counsel, or other spokesperson.
G. Right to Complain About Vendors. Each applicant will be notified of their right to complain to the local agency/clinic about improper vendor practices.
H. Program Explanation. During the initial certification visit, each participant/authorized representative will receive an explanation of how the food delivery system works; of the illegality of simultaneous participation in more than one (1) WIC Program; and that they will be terminated from the Program if they fail to pick up vouchers for two (2) consecutive months.
1. Referrals. Participants who appear to be eligible for the Food Stamp Program, Medicaid and/or Aid to Families with Dependent Children (AFDC) shall be informed of these programs and be provided with the addresses and telephone numbers of local/State offices. Participants must also be advised ofthe types of health services available, where

CT-29

GA WIC PROCEDURES MANUAL FY '96

they are located, how they may be obtained, and why they may be helpful.

m;

1. Mid-Certification mit6i!i1iIrerrnination. Reassessment of ~ilID.Eligibility - The local
agencies may disqualify an individual mm';E\{t8m:a Certification Period, on the
basis of a reassessment of program eligibility status if the individual is determined ineligible. Reassessment of a participant's 1~~I~!eligibilitystatus is not mandated but must be done if there is reason to believe a participant's !ij~~I~:l~tatus has changed (e.g. laid otTworkers being rehired, participant's winning a judgement in a lawsuit). When income eligibility is reassessed ~.gjmid-certification, a thorough re-evaluation ofthe programs for which the individual could be determined adjunctively income eligible is required. If the participant does not qualify based on adjunctive eligibility, then eligibility must be determined based on income quidelines. If the participant is determined to be ineligible, the local agency must disqualify the individual. The Notice of Termination/Ineligibility/ Waiting List Form must be issued when an applicant/participant no longer qualifies for the WIC Program.
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..

The policy(s) for implementing a Certified Waiting List wiD be issued by the State Agency. The policy(s), prior to distribution to Local Agencies for implementation, will be approved by the USDA Regional Office.
~ INELIGmILITY PROCEDURES

All persons determined to be ineligible for Program benefits on the basis of residence, income, or nutritional risk will receive a Notice of Termination! ineligibilitylWaiting List Form?iil@!t! (Attachment CT-14)

Procedures for Completing the Notice ofTerminationlIneligibiliJylWaiting List Form:

. 1 1. Fill in applicant's name and date at the top of the form

41~ll~l_

P!lQ'l1w1_ifl;;~I~gl'~.

2. Mark the box which states "You are not eligible for the WIC Program because

you... "

3. Check the reason for ineligibility.

4. Complete in 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.

Processing standards regarding notification shall apply. Applicants wi!! be notified of their

CT-30

GA WIC PROCEDURES MANUAL FY '96
right to request a fair hearing regarding the ineligibility determination. A copy of the form must be filed in the individual's health record and/or the ineligibility file.

Persons determined to be ineligible must also be asked to read (or have read to them if they cannot read) the Rights and Obligations Handout and must read and sign the back of the WIC Assessment/Certification Form.

Ineligibility File. Clinics are required to maintain an ineligibility file. Each clinic may establish their own system for maintaining such a file, as long as the following guidelines are followed:

A. Ineligible Applicants Without Health Records

For applicants who do not have a health record in the clinic, the ineligibility file must contain the following:

1. Applicant's name 2. A copy of the Notice of TerminationlIneligibilitylWaiting List Form 3. Date the ineligibility action was taken 4. All supporting documentation, e.g. dietary recall, growth charts, WIC
Assessment/Certification Form, progress notes, etc.

B. Ineligible Applicants With Health Records

The four items listed in A 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 Notice of Termination/IneligibilitylWaiting List Form must be kept in the ineligibility file. If a copy oftheir Notice of TerminationlIneligibilitylWaiting List Form is filed in the ineligibility file, it does not also need to be filed in the health record.

Ii:{ VERIFICATION OF CERTIFICATION (VOe) CARDS

A. vec Card Definition

vec A

Card is a negotiable instrument issued to or received by participants who are

transferring from one city/state to another.

B. Required Data

vec When a

card (Attachment CT-15) is issued to a participant, at a minimum, the card

must contain the following information:

1. Participant's name

CT -31

GA WIC PROCEDURES MANUAL FY '96
2. Date the last certification was performed 3. Date income eligibility was last determined 4. Nutritional risk criteria (Do not use Georgia risk factor codes) 5. Date the certification period expires 6. Signature and printed/typed name of the certifYing official 7. Name and address of the certifYing clinic 8. Participant's WIC ill # 9. Participant's date of birth 10. EDC date (if applicable)
C. Orders
VOC cards must be ordered by the local agency from the State WIC Office. Clinics will order VOC cards from the local agency. Transmittal forms must be used when sending VOC cards to the clinics.
D. Inventories
All local agencies and clinics are responsible for maintaining an inventory of all VOC cards. The State VOC Card Inventory Logs (Attachments CT-16 and CT-17) must be used by alllocaI agencies and clinics. When VOC cards are received, the card numbers must be recorded on the inventory log.
A physical inventory ofVOC cards must be performed by local agencies and clinics. The physical inventory must be documented on the State VOC Card Inventory Log. One staff person must conduct the inventory and a second staff member must verifY by signing their initiaI on the inventory. Both staff members must initial the log. (i.e. "Physical Inventory Conducted" with the date and initial of one (I) clerical staff and one (1) CPA)
E. Issuance
A record ofthe 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: (See Attachment CT-16)
I. VOC card number 2. Participant's name 3. Participant's WIC I.D. number 4. Date the card was issued 5. Initials ofthe staff person issuing the card 6. Signature of Parent/Guardian/Caretaker (A Proxy cannot Pick up a VOC Card)
7. 1.!L~~i!l~lmtwg1!i~tl:E\llli:
8. On Hand Column
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GA WIC PROCEDURES MANUAL FY '96
When the Local Agency issues VOC Cards to the clinic, the following information must be documented: (See Attachment CT-17)
I. Clinic name 2. VOC card number issued 3. On Hand column 4. Received from State 5. Name of CPA 6. Date 7. Initials of one (1) clerical staff and one (1) CPA
F. Security
VOC cards are negotiable instruments, therefore, the security of the cards and the accompanying inventory log is imperative. VOC cards and their inventory log 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.
G. Lost/StolenlMisplaced VOC Cards
In the event a VOC Card is lost, stolen or misplaced, the State WIC Office must be contacted immediately.
If or when a participant reports losing a VOC Card issued by a Local Agency, replace the VOC Card, and contact the State WIC Office immediately.
Anytime a VOC Card is lost, stolen, misplaced or reissued, an Action Memo will be sent to all Local Agencies by the State Agency so that you are aware of Status ofthe Card.
When five (5) or more VOC Cards are lost, stolen or misplaced, the Notification Summary ofMissing Vouchers/VOC Card Form must be completed. (see QI Section). Once this report is received, an investigation will be conducted by the Office ofFraud and Abuse and Notification oflost VOC Cards must be reported to USDA and States in the Southeast Region will also be notified.
H. Instructions for Use
Clinic staff must:
I. Ask all participants at each certification if they plan to relocate during the certification period.
2. Issue a VOC card containing the required information to any participant who is
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GA WIC PROCEDURES MANUAL FY '96
likely to relocate during their certification period. All migrant farmworkers are to be Issued VOC cards. For those participants transferring within the State of Georgia only, a copy of both sides ofthe WIC Assessment/Certification Form may be given to a participant in lieu of a VOC card. However, records must be retrievable at the initial clinic site.

3. Instruct the participant receiving a VOC card on its use and encourage them to continue participation in the Program in their new location.

4. Assume responsibility for the security of the VOC cards and maintain records of issuance to individual participants.

Rtl

5. Clinic staff must place either a copy or the original VOC card in a file/record of the transferring participants (i.e., migrants).
TRANSFER OF CERTIFICATION

A. VOC Card

All clinics will accept a valid VOC card from participants who have been participating in another state, district, or local agency/clinic, even if the out of state participant does not meet Georgia's eligibility criteria. The card is valid until the certification period expires and must be accepted as proof of eligibility for Program benefits. These participants will be provided WIC benefits until their certification period expires, if caseload permits. Do not reassess an individual who is in possession of a valid VOC card since this card indicates that the person is in a current certification period.

During a waiting list period, the transferring participant must be placed on the Program regardless of priority.

Occasionally, a VOC card is presented which is incomplete. As long as it contains the participant's name and date of certification and the certification period has not expired, the participant must not be penaJized, i.e. they must not be denied benefits. Whenever possible, contact the certifYing local agency/clinic for complete information.

B. Phone Call

If a VOC card is presented which does not contain the necessary information, or the participant does not have a VOC card, clinic staff should attempt to contact the certifying local agency/clinic for the information. Documentation of the phone call must be made in the participant's health record and must include the following:

1. Date of the call 2. Name of the person conversed with

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GA WIC PROCEDURES MANUAL FY '96
3. Certification date 4. Height, weight, and hematocrit/hemoglobin 5. Nutritional risk factors 6. Priority 7. Assigned food package 8. Date vouchers were last issued 9. Date income eligibility was last determined (migrant farmworkers only) 10. Participant's WIC I.D. number (Georgia transfers only)
The phone call must be followed up with a re above from the certifYing local agency/clinic.
C. Georgia WIC I.D. Card
If clinic staff are unable to obtain the necessary information by phone, a valid Georgia WIC LD. card may be accepted in lieu of a VOC card. This should be done only when immediate certification seems imperative and stafffeel the LD. card strongly indicates that the individual is eligible. A participant who is transferred using a Georgia WIC I.D. card will be issued vouchers for one (1) month. Prior to the next issuance, clinic staff must contact the certifYing clinic for verification of eligibility and certification information. The phone call and all information obtained must be documented in the participant's health record. The call must be followed up with written documentation from the certifYing clinic.
D. Certification Record
Participants may want to transfer into a clinic with a copy of their WIC certification record from Georgia or another state, in lieu of a VOC card. This is allowable as long as the certification record contains all ofthe following:
1. Participant's name 2. Certification date 3. Height, weight, and hematocrit/hemoglobin 4. Nutritional risk factors 5. Priority 6. Assigned food package 7. Date vouchers were last issued 8. Date income eligibility was last determined (migrant farmworkers only) 9. WIC LD. number (Georgia transfers only) 10. Signature of certifYing local agency/clinic official
Clinics which receive a substantial number of certification records from participants who are transferring from another state, in lieu of VOC cards, should
CT-35

GA WIC PROCEDURES MANUAL FY '96
E. VOC Card Poster
A VOC Card Poster Qike the "And Justice for All" Poster), must be placed in a conspicuous location in all WIC Clinics. The purpose ofthis poster is to inform the WIC participant of its availability when moving.
CORRECTING MISTAKES
At minimum the following procedure must be followed when a mistake is made on an official WIC document:
1. Make a single Ime through the error. 2. The person who made the error places hislher initials and date near the error. 3. The correct response should be written near the line.
The word "error" may be written just above the actual error.
Correction fluid ("white-out") ml{V not be used to correct mistakes on official WIC documents.
"Official WIC documents" include, but are not limited to: WIC Assessment! Certification Forms, I.D. cards, VOC cards, voucher registers, inventory logs, and health records.
Under no circumstances may WIC vouchers be altered or corrected.
Eli GEORGIA WIC RESOURCE REFERRAL GUIDE
The Georgia WIC Resource Referral Guide provides valuable information on health, social service, child development and parenting education programs which participants or applicants may be referred. The programs listed in the guide are:
1. Food Stamps 2. WIC Program 3. Child Support Recovery 4. AFDC (Welfare) 5. Medicaid 6. HeadStart 7. Child Health Services It is a Statell~gl'~ Agency requirement that each new participant be issued this
CT- 36

GA WIC PROCEDURES MANUAL FY '96
;'ii~ilii~i~ii!1i~.th;~~:~~r~:rt~~:~~::~s~~lj!~~~!!~~:!!!~~~~:~!~
during the course of Program Eligibility.
The State Agency is responsible for printing this resource booklet. All clinics are required to maintain an adequate supply. The issuance of this booklet will be monitored during the biennial program review visit. Local Agencies (District Offices) may duplicate this booklet as needed.
The Georgia WIC Resource Referral Guide must be ordered through Central Supply. The order number is 3297.
RETROACTIVE BENEFITS AND REIMBURSEMENTS
WIC regulations do not provide for retroactive benefits and reimbursement regardless of circumstances. The WIC Food Packages are designed to be consumed within a specified time period when participants are experiencing critical growth and development.
WIC VOLUNTEERS AND CONFIDENTIALITY
In order to" prevent breach of confidentiality, the Georgia WIC Program must exercise discretion in screening and selecting capable volunteers who would have access to 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 actions steps must be taken in order to maintain participant information:
1. Once volunteers are selected, specific confidentiality requirements governing the WIC Program must be covered in the orientation or training of volunteers.
2. Follow-up training must be conducted periodically to remind volunteers, as well as paid staff; ofthe importance ofmaintaining the confidential nature of participant information.
3. The selecting agency may have volunteers sign an agreement acknowledging restriction 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 for the volunteers the importance of maintaining confidential participant information.
4. Ifa potential volunteer does not appear to be a good candidate for keeping information confidential, there may be other activities that the person can perform that would not include access to participant information.
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GA WIC PROCEDURES MANUAL FY '96
Em. PROGRAM PARTICIPATION
Definition:
A participant is a pregnant, postpartum or breastfeeding woman, infant or child who is certified to receive WIC vouchers. Program participation is the sum total of participants who receive vouchers during a specified reporting period. Participation is a valuable indicator for the WIC Program operations and must be monitored on a regular basis. The participation reports generated by data processing contractor are tools for monitoring program participation.
Non-Participation:
Non-participation is determined by vouchers created (manual or computer) for a WIC ID and are returned voided unclaimed to the bank or data processing contractor. Participants in a valid certification period who do not pick-up or redeem vouchers are counted as nonparticipation. Non-participation impacts the efficiency and effectiveness of the WIC Program. Regular assessment of individual clinic rate will assist Local Agencies in maintaining compliance with state's standards.
Non-participation rates above the state standard of 10% is considered a deficiency in Program Management and Operations. To improve the non-participation rates the procedures listed below must be followed:
1. The designated state staffwill contact WIC Coordinator whose district(s) has clinic(s) with a non-participation rate above 10% by telephone.
2. Within twenty (20) days of the telephone call, the Coordinator must submit a written report (see Attachment CT-30) which includes the following:
a. The possible reason(s) for the rate ofnon-participation.
b. Plan for correction (including objective(s), action steps, milestone timeframes, monitoring plan, re-evaluation plan). The coordinator will have ninety (90) days to improve the non-participation rate.
3. If the non-participation rate has not improved by the end of the ninety (90) day action plan period, state staffwill provide on-site technical assistance.
4. The Non-Participation RatelTechnical Assistance Summary Report (Attachment CT-30) will be used to document district response to the non-participation report.
When a technical assistance visit is required, the following procedure will be followed:
CT-38

GA WIC PROCEDURES MANUAL FY '96 a. State staffwill contact the WIC Coordinator to schedule the date and time. This technical assistance visit must be scheduled within thirty (30) days from the last day of ninety (90) days action plan period. b. Training will be district or clinic specific at the discretion of the WIC Coordinator and designated state staff
Follow-up monitoring ofLocal Agency action will begin after two (2) months of successively high no show rates. MANDATORY NO-SMOKING POLICY IN LOCAL WIC CLINICS 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. Prohibition against smoking applies only during the hours of actual WIC operations. In the event that clinics or voucher issuance is being held at a satellite clinic (ie church, public housing clinic site, community health center only once or twice per week) then the nonsmoking policy would only be in effect during WIC operation hours. If the health department is a non-smoking facility, and such signs are displayed throughout the health department, then there is no need to display a WIC specific non-smoking sign.
CT-39

GA WIC PROCEDURES MANUAL FY '96 CT-40

GA WIC PROCEDURES MANUAL FY '96 CT - 41

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-1

WIC ASSESSMENT/CERTIFICATION FORM - WOMEN (FRONT)

it.

-

o=LJ o=LJ 0 0 WlCIONUMIIlt

~

IlIIlTHCATt

ADOltESS

DI'(OOI

COUNn

ITEUPftON.

ISOCIAL SIQllUT"f NUMIEIl

~~~~;t~iJ:"
INITIAL (ONTACT DATE.

";~.

.~: . "-'t~-..... " . . ,

OAT( OF ftllST VISIT III QUESTING WI( SEIlVlQS (IIv,,<frt....... f.;(C'M~f""'''''''"''''''''''''''

ETHNIC OII.1GlH p . - _

I MIGUHT'

0 - 0" Ow 0- 0"'10_ 0100

I'lItHATAl

I'I'I'IIIISTFO

11I5TFO fONl '"

YES

NO

YU

NO

YES

ICO

IS THE CLIENT INCOME EUGIIU?

. . IS THE CLIENT ,IlEGHAN" __ ,oc
J:IStlT-H:E:~C-L=l"U:I:T'l~II-E;A:S=T=:F=E=E=O:I:N~GJ~A(N~-I:H'-F~A""N'T:;U:S=S="T'H~=A=N"''~Y-l-A~:I'lQ:"f;A"G;-U:;==::;=~""'=:. ~~<l:'~ c~; ~~. :"'.

.~
---

6i
-l----

i

~

~

IS THE CLIENT USS THAN' MONTHS 'OST'AIITUM.NOH..IIIASTFUOtHGl

I-=tl:-:':-=':Z,':-======~J~(":":"::""!:":'=="'=:=:::"'::"=:.=:.-~.=.-=:.:==:. .=..,~

.

MECHCAlOATAOATE rr_ ..........., - .

~

..,,!cit(

"",atocritI H"mo;lebltI

'IlENATAl

yn

NO

'''IIISTFO

YES

NO

USTFO 10NlYl

YES

NO

Nut,itioft,nv 1I.1.tod Modical CoftClitioftt

I

Didtu Of HvDOalvc.....i.

IC

~ttatiotl,l HvO"rt"ftslv" DltO,d,,"

_ -.1 l

MvltiDlt FttusUOf lirths

-

M

.ft., IDC or o.r.v",v O.t.. leu th.ft 25 Moftths

T"rtlIin.tIoft of lart ".Gna..CY

Kistoryofl_Iinhw"ightlft',ftt!t)

.........- . , . . _ - . ,

N

,.st f'et:. ~ .,......,., te UOO r"........ S "I ~
Hirtonr of Ifthnth! Guutio".l Ao" than )I wks _~_.,.._-<I ,

HirtCl<Y of FoUl 0' N"on.tallon

_ " ' _ . ""_ _II Q

ELIGIBlE FO~ WlC

TOOArsCATI

CT- 42

.. ~.

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-1 cont'd

WIC ASSESSMENT/CERTIFICATIONFORM - WOMEN (BACK)

OAT[

MOlCAlO CUllllNTYIN

INCOME DETERMINATION

MOlCAlO 10 NUMIl1l

fOOOSTAM~ NO. IN CUIIII(NTYIN ~"'M'tV

GIIOSS IffCQMEIMO. (CUlll\ENT 011 ANNUAl)

- '_.'

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 1have given is my total gross household income (~II ash Income before deductlOf'ls). This certification form is being submitted in connection with the receipt of Federal .ssistance. 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.

A~NT SIGNATUllE

DATE

SIGHATUllE Of WlC OffICIAl

.'

-

DATA NEEDED FOR PREGNANCY SURVEILLANCE

Marital statue (0 .Ma"'*'l. ,. Nor MarMd t. Unlt_Itl

'.anoUducatlon compl.ted ( 'ltgrad Of. Z Yrs.Coll~. '4. " . UnkftOWnJ

Ii : , . Month of gestation at tim. of fW1t pr....tal.xam

~'l.f~=n I ~r..

hr me..., ItJt 0< ,til mOo

(FOR USE AS DISTRICT OpnON)

TOPIC

_I..,. DA1I

SECONDARY NUTRITION EDUCATION

D..1I0I
COIfTACf

_fMIWI DA1I

DA1I0I
COtlTACT

-...llIT DA"

0A1IClf
CCll&UCT

SIGNATURE/TITU

FOOD PACKAGES

WlCTYP

(00

MILK

(HUSE GGS JUICE (REAl

PRENATAL OR
BREASTFEEDING
.

407 406 -C05

7 VIIs 5Va1s
11qts_~

0 21bs Jibs

2doz 2c1oz 1c1oz

'clns 'clns 'ani

J'DZ J60z J'OI

M4

4gab

21bs

2doz 'ani Hoz

COJ

Cgals

11b

1 cIoz 4anl 1402

CO2

2911s

21bs 2d02 'Clns J60z

cot

4glls

0

1 cIoz 4canl Ho.

POSTPARTUM

50J

NON-

S01

IREASTFEEOtNG

S01

'gals JlIab J~b

0

1 den 4unl J' ...

21bs

1d... Cunl 24_

0

"oz 1 cIoz IUfti

Pltlent mutt haw Ilgntkymptoms of lACTOSE ~rOLEIfANCEd _ n t . d 1ft ttlcl< ,"edial ,.<01.
See Gcotila WI( I"oc.cdurel MaftUal for addit~1food Padage dct.,mlftation.

DIUED PASIIUNS 011 PEANUT tUnER

tlb bunllpus Of t. OZ pelnut bvttcr

t Ib bcanllpeu Of tt 02 pelnut bvtt.r

lib bcanllpeu or 11 en peanut bvtt.,

lib bcanllpeas or ' . !'Z peanut bvtt., 11b bcanllpell or 1i 02 pelnut bvtt.,

11b bcanllpeas or ,. en peanut butter

t Ib bcanllpeu or 11 02 peanut butter

.

0

0

0



CT -43

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-2

WIC ASSESSMENT/CERTIFICATION FORM - INFANTS (FRONT)

........ ~pa_."H_"II._<fl Division." Publ"oc ~.lttI

OJNICo=IJ

NAME

VoSf

..-sf

-..........

allUHOATE

AOOItUS COUNTY

ITELEPHONE

'ARENTIGUAROIANiCARETAKER NAME:
MOTHU'S IIRTHOAV. . ... ::'.L .: .00

OTY
ISOCIAl SECURITY NUM.ER

I to-*_ ETHNIC OItIGIN 0- 0'" 0"

co. 0-

Z.COOE
,I OAS aMlnGItiANT0110 ISEX 0 - 0 -

l~ Wt. kfo,c ~livery: .">""0 ':; . : ' Mos. CertA.60.ut 1st ""....t., h&Min1W~~{f.{<F~

INITIAL CONTACT OATE

01.TE OF FIRST VISIT RE QUESTING WlC SERVICE S

~ f.(to O,,"d~v," ~ ............tt...... IS THE CLIENT INCOME ELIGtllLE7
MOfCAl C!AT& OATE fftf".f.#te.ttM~_""'f""vr............ r.""J
ufl91!\

Wc;ght (Enee, birfIt....;glot

lb.

ozJ

~",ato<,it I He"'oglobi..
f1.,. .. .) RECOIlO THE NUM8ER OF WUI(SINFANT WAS .REASTFEO 1"..'._f.f.4...l.t.t."._ u..U.. ,... to. "'_.

YU t NO
I
. ........

MIOCERT.
", YU_. I NO ~.:.~-:m . ....

~~

......

......

ChedI (~CheetI.... y. . . . . . .~ Wf'h.. N'"

f l _ " Iron ~f't(;en<yS<,....;,,~ Vllue (,<I.....

ffCI': .... _ .." .. ""- .............. .-.J

~ES

NO

YES

NO

A

_v.... "'" ___ .,Iow S,"nd"d Weioht fa, Lenath ,................'to .,. _
Abo"e Standa,d We;"ht {Of L.noth , _..........

. ., 110'

I C

lowlenatlolfOfAa., (10..............' ....,............,

E

Not Fonowino R.comm.,nd.,d 'att.,.. of G,owth

F

ClWcal Mana.,tation, of Mal..ut,itio.. ~ntal P,obl.,,,,, lud Polsonino

I

Nut,ition.n" R.lat.,d M.,dical Co..ditio.., low It~iaht "",,, tflaftOf',,~'fO lSOO .... ." HI~' e;."utional AQal." Than 38 wukl Cl'At., ......." ......
ftM_, ..", tnfantofl.,.,astfe.clinaMoth...tllisk Il..... _ . _ ..
',."ne_ Infant ("" to ,i. mont'" o(a".,1 0(. Wle Mol"., or MOllo., wit" Nuf,ltional Itisk Dur1ft<J

J
,0
V W

InadeQuata Di.ta,y 'att.m en......... _ ... WfC "._"",

X

ELIG18LE FOR WlC

cx'" 'RlORlTY: ..... (I'ClO ..,

'"'WI

FOOOPACKAGE: ~r""""",,_,_,

MA Y UPGRAOE AN INfANTS 'RIORITY AT MID-<:ERTIFICATION NEVER DOWNGUDE

.- ,.\:
I
..' "~""~

_tq.'_ _ IllL_.1"_""..._...f.l..O. l SERVlCU: OllAl.I'SOf tt~CM$ 1Q, _."" II~ _

.... IGI

_ _ l l I . M _ I M ~ A l O C t N L M

IMl. ....... _ ,

TOOl.YOS OATE

I '" _ _ .tw.es.4 .... 1 ...,....... T.

SIGNATURE AND TITLE OF HEALTH PROfESSIONAL COMMENTS:

(FOR USE AS DISTRICTOPTION)

TOPIC

"PO()IffTWINl
0""

SECONDARY NUTRITION EDUCATION

D"n Of COtftACT

_Ol'lrMIIIT OA"

DAttOf (OfiCTACT

_rwlffr
0""

DATtOf
CO-TACT

SIGNATURE (TITLE

fot'" 32" (ll.,v. 1-92)

CT-44

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-2 cont'd

WIC ASSESSMENT/CERTIFICATION FORM - INFANTS (BACK)

DATE

MED:Ato CUIUlEHTYIN

INCOME DETERMINATION

MEDICAID lO HUMIII

fOOOSTAMI'S NO.tN CUfUUNTTIIC fAMILT

"OSS IICCOMiMO. (CUIlIlEHT OA ANNUAL)

.
I h..ve been advised of my rights and obligations under the Program. I certify that the information I will provide. or h..ve provided is correct. to the best of my knowledge. The income I have given is my total gross household income (.." ash income before deduct/ons). This certifiution 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 pt'osecution under State and Federal law.

PAIlENTIGUAIIDlAHltCAllnAICMtlOlCT SIGHATUllr
-

DATE

SIGNATUllE Of WlC OffICIAL

INFANT FOOD PACKAGES

coor

CONTAACTrD FORMULA: (Slmuc 11somir)

CODr

IRrASTtEo INfANTS (S;mil~c I/,omll.,,, SlIppl.me"tj

t52 2S caftl r..dyot""eed

299 (lArASTH EDING MESSAGE)

1SS 25 caM r..dy-tOofH<!. 2 oftl/ulce. 2C or c....,

22t 2 anllulce, 2C Ole....,

tSJ Jl cansconcefttflte

256 13C,nI concefttute

t56 J1 caM concentt,te, 2 Uftl )<Ike, 2C or ce,'

257 13 ca"ICOftCe"tr~te.2 caft./ulce, 2c or c....1

151 310M conce,,'tate, 2 am juice

2U t an powde.ed

1st 31 caM _enttale. 2 an.julce,16oHe...'

261 JOftlpowded

163 aM powdered

26C 1 can powded. 2 ca". Juice, 2C or c.r..'

t56 cam powd.red. 2 aMjuic., 2C ou....t

265 J canl powded, 2 ca". julc 2C OZ cal

coor
tu
'"

NOH-COHTAACTEO fORMULAS: (E,,'"ma, fro'~..SMA. Hllnay, Good StI~ Follow-Up, GeMr, Soy~I~c.f-Soyau<)
Of' ""rskl~n.o<d., ,equl,ed
J1 caftt conc.fttrate cans powd (Does Hot Conuln carn~tion followUp)
Of' J1 UftS conc.ntrate can. powder. 2 can'Julc., 2C or c.fI~1
(V.. Only 'Ot In'ants z: 5 months)

.bo". At9t food packag. may be ptelCllbed by the Compet.nt "ol.ulon~1AuthOtlty If none 0' the

can b4 tailOted 'PP'01lrl.te1y.

See Geocvla WI( ProCH"'es MIl_I fo< additional 'ood Package det..m""'tlon.

CT -45

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-3

WIC ASSESSMENT/CERTIFICATION FORM - CHILDREN (FRONT)

co-rgla oe""_ntof"'-aft ...........

0IvId0ft of PublIc He.1th

QJHIC [ I I ]

1m []:=J

NAME

u.sr

fIlU

-..- I IUtTHDA'rE

AOOflESS COUNTY

ITWPHOflE

PAIUNTIGUAIlOlANlCAIIETAKEIINAME

QTY
Isocw. SEc.ulUTY NUM'~11

alP ETHNIC ORIGIN lCJoe'* 0Ml
0- 0 ..

ZlPCOOl

GA
I ;I 0-

Cl AS aMlGftISlANTCl...,
aSEX... a -

DATE Of fiRST VISIT REQUES TING WlC SERVICES (liful'f ~ ufW H Nf'fH'c:.f'o<o't .,.. #!Ofmo"H('V(Iw' 0-:41 h<h QlHtd... v..... w.... Wrft. MIA
IS THE OJENT INCOME ELlGlllU
MEDICAL DATA DATE _ _ ""'-. _ _ _ _.......,
IJn<!thIH....ht
w.~ht

YES NO YES I NO YES I NO YES I HO

...

...

...

_atoeritl H....ogloblft

~~~ ~

V.,...Ctwdt fHt. ~OftYft et' If.... Wo1tl ....A.
Iron oe~l\C)'S<teening
'"""' UU_HC1"Ooloa "-~1I... - . .... _ ,U ....., '"""' ~.~ Her."" "-Jell ..........., , _ u ...r.J
1I.k>w Standard Weiaht forlenathIH.laht ..... _ ... _ .. ,..~_J Abov. Standard W.iaht for l.nathIH.iaht ._.,.,_... _ ,..... _ ,..,

YES NO YES NO YES HO YES HO

A



..

C

1I.lowl.nathIH.icht for Ac...... "-... uM.. fA~1

E

Not Followlna R.<omm.ncl.cl Pattem of Growth er",ka' M.nifutatlons of Malnutrition oentalPro~rn. laid Poisonina.

f,

Nutritlonany Relat.d M.diul Conditions

J

In.d.ouate Di.Urv P,tt.rn 1....IHd .. _ ... Mt""'-NhI

X

p"".ibirrtv of ReQr...ion ""A_ ..........._"

Z

ELlGllILE FOR WlC

PSIIORITY: J.",ICfFIIZl
FOOOPACICAGE: ~r..

.

.

.

.

.

.

_ '-"'

I_ I

-'-lGI. lCl.""" SEIlVlCES: (N(Al.I01OT lIl. 01.

-lIl. ,-, ........... tiL

_ _ ~""""'",--lII..tlIUL

(Q,'_'-~"_lMJ,

UllC(IQ, _ _ lOLlloM ..... lI'I. 0Ih....... opodfJIQI

_...
......,...T.

TOOAY"SOATE

SIGNATURE AHO TITlE Of HEALTH PROfESSIONAL

COMMENTS:

TOl'1C

SECONDARY NUTRITION EDUCATION

OAnOl CofACT

CATlOl CofAC!"

SlGMATUIlE/Tme

fomo )215 (llevOo '-92)

CT-46

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-3 cont'd

WIC ASSESSMENT/CERTIFICATION FORM - CHILDREN (BACK)

OAn

MEOlCAIO CURRENT YItf

INCOME DETERMINATION

MEDt<:...1O 10 NUMBR

fOOD STAWS ICO.tH CURRENTYM f ...MIlY

~ss INCOMEIMO. (CUMENT Ott ANNUAl)

.,

I have been advised of my rights and Obligations under the Program. I certify that the information I hav!! provided is correct. to the best of my knowledge. The income I have given is my total gross household Income (an ash Income before deductions). This certification form is being submitted in connection with the receipt of Federal uslstance. 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.

.....RENTIGUAROI... NKARETAI(ERIPROXY SIGNAlURE

O"'TE

S~NATUREOF~O~Al

W1CTYPE
CHILDREN

eooE 607 606 '05 60C 603 'OZ 601 600

FOOD PACKAGES

MilK 'g,ls _g.ls 16qt!p....o....""'''O -g.ls Cg.ls Z g.ls
,
4g.ls 2g.'s

(HEESE

Zlbs 21bs Zibs 11b Zibs

1lb

EGGS
Z~
Zcfoz
Z~
2cfoz Zcfoz
Z~
1 cIoz 1cfoz

JUICE 'aiM 'aiM I aiM CalM CalM CalM _aiM CalM

CEREAL Uoz 360z 2_oz ZCoz Uoz Z4j)z Z_OZ 1Ioz

DfUEO PEA$/IEANS OIl ..EAHUT IUTTEIl 11b be'M!pe.s or ,. oz ....nut butwr
l' 11l> be.nsfpeas or 1. oz pe.nut butt.r
11b be.nsfpeas or oz ....nut butt , Ib be.nsfpe" or 1. oz ....nut butter
0 11b be.M!peas or ,. oz ....nut butt.r 11b be.M!peas or 1. oz ....nut butt
0

PeWnt .....st have signsfsymptoms c:f l.lCTOSE INTOlRANl:E do<umentecf In tto......atcal r.-cf. A t9t food ,.<bge m,)' ~ ptes<rlbed b)' t!we (om~tent 'rofusion,1 Authority If none oftM.bove an be talloted .ppropriately. See Georg" W1C I'rocedures M,nual for .dd"ot;o",1 food '.<hge ckt.........tlon.

CT-47

GA WIC PROCEDURES MANUAL FY '96 SIGNED STATEMENT OF INCOME

Attachment CT-4

I,

~ cannot come in to apply for WIC for my

Parent/Guardian

child(ren), Narne(s) ofChild(ren)

. I have given permission to

_ _ _ _ _ _ _ _ _ _ to file my application. The total gross income of my Proxy

family is $

per

. The number of people in my family is

Parent/Guardian Signature

Date

CT-48

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-5

VERIFICATION OF INCOME FORM

INSTRUCTIONS:

Prior to verifying income: Date and sign the top of the fonn. Complete items 1-2. Complete the bottom half, detach, and give to participant. Record date and initials from the bottom half on the top half.

After receiving verification: Complete items 3-4, date, and initial. Document any and all actions taken. File in medical record.

Today's Date:

Staff Signature:

-,-_

1. Participant's Name:

_

2. Reason for requesting verification:

Date verification requested (same as date on bottom half):

Initials of staff requesting verification:

_

3. Method of Verification (please attach): _ _Pay stubs _ _Employer statement (or other responsible person) _ _Most current tax return _ _On-going records (self-employed only)

Date verification received:

Receiving staffs signature:

_

4. Action taken:

_

(Complete bottom half, detach, and give to participant)

Date:

_

Staffs Initials,

_

At certification you signed a statement verifying your family size and gross income. We now have reason to believe that this information may not be accurate. Based on Federal Regulations and Georgia WlC Program Policy, we have the right to request verification of your income. Acceptable forms of verification are:

1. Pay stubs 2. Official statement from employer (or other responsible person who can verifY your pay))
3. Most current tax return 4. On-going records (for self-employed only)

CT-49

GA WIC PROCEDURES MANUAL FY '96

You have thirty days from today to provide this WIC clinic with one of the above acceptable forms

ofverification. Ifyou fail to submit this by

you will be terminated from the WIC

Program. If the income determined through verification exceeds the income scale, you will be

terminated from the WIC Program and may be required to pay the State agency, in cash, the value

offood benefits improperly issued to you.

This is an Equal Opportunity Program and is operated in accordance with the U.S. Department of Agriculture policy, which prohibits discrimination on the basis of race, color, national origin, sex:, age or handicap. Any person who believes he or she has been discriminated against should write: Secretary of Agriculture, or the Office of Advocacy and Enterprise, Washington, D.C. 20250.

CT- 50

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-6

DATA AND DOCUMENTATION REOUIRED FOR WIC ASSESSMENT/CERTIFICATION

WOMEN

Documentation

Breastfeeding

Postpartum NonBreastfeeding

Height

Required

Required

Required

Weight

Required

Required

Required

Hct orHgb

Required

Required

Required

Prenatal Weight Grid

Required

N/A

N/A

Dietary Intakel Summary

Required

Required

Required

Dietary Evaluation

Required

Required

Required

Risk Factors

G, H, I, J, K, L,
M, N, 0, P, Q, R, S, T, U,~
As Required

G, II, I, J, K, M, N, 0, P, Q, R, V,[~t~
As Required

G, II, I, J, K, M, N, 0, P, Q,R,~
As Required

NOTE: Refer to Attachment CT-18 for information regarding the collection of height data. Refer to Attachment CT-18 for information regarding the collection ofweight data. Refer to Attachment CT-19 for information regarding hematological equipment. Refer to Attachment CT-20 for information regarding use of the Prenatal Nutrition Assessment Form. Refer to Attachment CT-21 for information regarding diet assessment.

CT - 51

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-7

DATA AND DOCUMENTATION REOUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Documentation

Infant Certified in
Hospital Prior to Initial Discharge or
Neonate QualifYing
as Priority n

Infant 0-6 Months

Infant 6-12 Months

Length

Birth Data or 0 ther measurement

Required

Required

Weight

Birth Data or 0 ther measurement

Required

Required

Hctor Hgb

N/A

Optional

Required

Weight/Age Plotted

Optional

Required

Required

LengtbJAge Plotted

Optional

Required

Required

Weight/Length Plotted

Optional

Required

Required

Dietary Intake/ Summary

Optional

Required

Required

Dietary Evaluation Risk Factors

Optional
I, J, 0, P, V, W, ~ As Required

Required
I, J, 0, P, V, W, ~ As Required

Required
I, J, 0, P, V, W, ~ As Required

NOTE:

Refer to Attachment CT-18 for information regarding the collection of height data. Refer to Attachment CT-18 for information regarding the collection ofweight data. Refer to Attachment CT-19 for information regarding hematological equipment. Refer to Attachment CT-22 for information on plotting growth grids.

Refer to Attachment CT-21 for information regarding diet assessment.

CT- 52

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-8

DATA AND DOCUMENTATION REOUIRED FOR WIC ASSESSMENT/CERTIFICATION

CHILDREN

Documentation

Length or Height

Required

Weight

Required

Het orHgb

Required

Weight!Age Plotted

Required

Length or Height!Age Plotted

Required

WeightlLength or Height Plotted

Required

Dietary Intake/Summary

Required

Dietary Evaluation

Required

Risk Factors

I, J, Z,@ As Required

NOTE:

Refer to Attachment CT-18 for information regarding the collection of height data. Refer to Attachment CT-18 for information regarding the collection of weight data. Refer to Attachment CT-19 for information regarding hematological equipment. Refer to Attachment CT-22 for information on plotting growth grids. Refer to Attachment CT-21 for information regarding diet assessment.

CT- 53

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-9

NUTRITIONAL RISK CRITERIA

PRIORITY

PREGNANT WOMEN

A IRON DEFICIENCY SCREENING VALUE

Hematocrit: less than 36% Hemoglobin: less than 12 gms

B BELOW STANDARD WEIGHT FOR HEIGHT

Pre-pregnancy weight is less than or equal to 10% below standard weight for height. Refer to Weight for Height Table, Attachment CT-22.

C ABOVE STANDARD WEIGHT FOR HEIGHT

Pre-pregnancy weight is greater than or equal to 20% above standard weight for height. Refer to Weight for Height Table, Attachment CT-22.
D NOT FOLLOWING RECOMMENDED RATE OF WEIGHT GAIN
1. Any documented weight loss during pregnancy.
2. Rate of weight gain above the upper or below the lower solid lines on the Prenatal Weight Grid (see Attachment CT-19). Applies to thirteen (13) weeks of gestation or greater.
3. Intrauterine Growth Retardation (IUGR)
Defined as: growth in fundal height less than one (1) cm per week or less than three (3)
cm in four (4) weeks (slow fundal height progression). A minimum of three (3) measurements should be recorded at two (2) week intervals to document slow fundal height progression.
G EDCPRIOR TO 19TH BIRTHDAY
H EDC AFTER 35TH BIRTHDAY

CT- 54

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-9 cont'd

PRIORITY

CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL PROBLEMS, LEAD POISONING, NO PRENATAL CARE

1. Classical clinical manifestations as described in Attachment CT-23. Anyone manifestation is acceptable criterion. Document description(s) of clinical sign(s) in participant's health record.

2. Dental problems severe enough to interfere with mastication and/or have other nutritionally related health implications. Document diagnosis in the participant's health record.

3. Lead poisoning as detennined by a positive laboratory test. Laboratory test results must be documented in the participant's health record. Document date of the test; must have been performed in the previous six (6) months.

4. Prior to the initial WIC certification, the applicant has had no prenatal care and is greater than or equal to 20 weeks gestation.

J NUTRITIONALLY RELATED MEDICAL CONDITIONS

Any disease or condition affecting nutritional status. As defined by but not limited to chronic disease, febrile conditions or infections, HIV positiv~ status or parasitic infections. Guidelines include but are not limited to:

1. History of parasitic infection in the past six (6) months. Document laboratory test and date in participant's health record.

2. In the past twelve (12) months a total of at least twelve (12) points, based on the following conditions and point system (approximate dates of each occurrence must be documented): Points (each)

a. Urinary tract infection;

4

b. Episode of bronchitis;

6

c. Streptococcus infection;

6

d. Simple cold;

2

e. Occurrence of pneumonia, severe bums,

12

major surgery, tuberculosis, hepatitis,

meningitis, cancer.

3. Presence of chronic renal disease; cerebral palsy; cardiac disease; cystic fibrosis; thyroid disorders; inborn errors ofmetabolism; any medical condition that interferes with the ingestion, absorption or utilization of nutrients and requires a therapeutic diet.

CT- 55

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-9 cont'd .

CODE a.

PRIORITY Chronic diseases or medical conditions which are directly related to nutritional status of the individual must be identified in the documentation.

b. Chronic diseases or medical conditions which are not directly related to, but may affect nutritional status, must be identified by a Competent Professional Authority. Documentation must include a description of how the disease or condition affects nutritional status.

c. Documentation for Lactose Intolerance must contain a list of symptoms described by the Program applicant/participant.

4. When using HIV positive status as a Nutritionally Related Medical Condition, write "SEE MEDICAL RECORD" for documentation purposes.

K DIABETES OR HYPOGLYCEMIA

Gestational Diabetes, Insulin Dependent Diabetes Mellitus (IDDM), Non-Insulin Dependent Diabetes Mellitus (NIDDM), or Hypoglycemia. Diagnosis and current diet prescription from a physician must be documented in participant's health record.

L GESTATIONAL HYPERTENSIVE DISORDERS

Document the presence of anyone (1) ofthe following in the participant's health record:

1. Pregnancy Induced Hypertension (Pili):

a. Blood pressure reading in 2nd trimester of 120/80 or higher; b. Blood pressure increase of30mm Hg systolic or 15mm Hg diastolic from pre-
pregnancy reading or first recorded reading at any time during pregnancy.

2. Pre-eclampsia:

I

a. PIH plus proteinuria greater than a trace in two (2) clean-catch urine samples collected six (6) hours apart;
b. PIH plus proteinuria plus ankle edema greater than 1+ in the p.m.; c. PIH plus proteinuria plus edema of hands, face, or abdomen.

M MULTIPLE FETUSES

This pregnancy only. Must be diagnosed by a physician or health professional acting under standing orders of a physician. Document diagnosis in the participant's health record.

CT-56

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-9 cont'd PRIORITY

N EDC LESS THAN 25 MONTHS AFTER TERMINATION OF LAST PREGNANCY

Document termination date oflast pregnancy and EDC in the participant's health record.
o HISTORY OF LOW BIRTH WEIGHT INFANT(S)

Woman has delivered one (I) or more infants weighing 2500 gms (5 pounds 8 ounces) or less at anytime in the past. Document weight(s) and birth date(s) in the participant's health record.

P HISTORY OF INFANT(S) GESTATIONAL AGE LESS THAN 38 WEEKS

Document delivery date(s) and weeks gestation in participant's health record.

Q HISTORY OF FETAL OR NEONATAL LOSS

I

a. Document date(s) offetaYneonatal death(s) in the participant's health record. This does not include elective abortions.

b. Neonatal loss is defined as a death(s) occurring to an infant less than 28 days of age.

R GREATER THAN FOUR (4) PREGNANCIES

Woman is pregnant for the fifth or more time. Document multiparity in participant's health record.

S CURRENT USE OF ALCOHOL

Defined as any current intake of alcohol during pregnancy.

T REGULAR USE OF TOBACCO

Greater than one (1) cigarette per day (average intake) and/or the daily use of other tobacco products during pregnancy. Other tobacco products include cigarettes, snuff, chewing tobacco, cigars, and pipes.

CT-57

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-9 cont'd PRIORITY

U CURRENT USE OF STREET DRUGS

Defined as any current usage ofillegal drugs (street drugs) during pregnancy. Including but not limited to: marijuana, cocaine and cocaine derivatives, heroin, amphetamines, tranquilizers, or barbiturates.

X INADEQUATEDIETARYPATTERN

IV

I. Any food group missing based on the Recommended Daily Servings Chart (Attachment CT-24);

2. Failure to meet the recommended number of servings for two (2) food groups;

3. Practice oftwo (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-25);

4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings for one (1) food group.

CT-58

GA WIC PROCEDURES MANUAL FY '96 NUTRITIONAL RISK CRITERIA
BREASTFEEDING WOMEN

Attachment CT-10 PRIORITY

A IRON DEFICIENCY SCREENING VALUE

Hematocrit: less than 36% Hemoglobin: less than 12 gms

B BELOW STANDARD WEIGHT FOR HEIGHT

Weight is less than or equal to 10% below standard weight for height. Refer to Weight for Height Table, Attachment CT-22.

C ABOVE STANDARD WEIGHT FOR HEIGHT

Weight is greater than or equal to 20% above standard weight for height. Refer to Weight for Height Table, Attachment CT-22.

D NOT FOLLOWING RECOMMENDED RATE OF WEIGHT GAIN

Inadequate weight gain during most recent pregnancy based on pregravid weight status.

Total weight gain ofless than:

a. 25 pounds if Normal weight b. 28 pounds if Underweight c. 15 pounds if Overweight

Document total weight gain in the participant's health record.

G DELIVERY DATE PRIOR TO 19TH BIRTHDAY

H DELIVERY DATE AFTER 35TH BIRTHDAY

CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL PROBLEMS, LEAD POISONING, NO PRENATAL CARE

1. Classical clinical manifestations as described in Attachment CT-23. Anyone manifestation is acceptable criterion. Document description(s) of clinical sign(s) in participant's health record.

2. Dental problems severe enough to interfere with mastication and/or have other nutritionally related health implications. Document diagnosis in the participant's health record.

CT- 59

GA WIC PROCEDURES MANUAL FY '96

CODE

PRIORITY

3. Lead poisoning as determined by a positive laboratory test. Laboratory test results must be documented in the participant's health record.

Document date of the test; must have been performed in the previous six (6) months.

4. Applicant did not have prenatal care during most recent pregnancy.

J NUTRITIONALLY RELATED MEDICAL CONDITIONS

Any disease or condition affecting nutritional status. As defined but not limited to
chronic disease, febrile conditions or infections, mv positive status or parasitic
infections. Guidelines include but are not limited to:

1. History ofparasitic infection in the past six (6) months. Document laboratory test and date in participant's health record.

2. In the past twelve (12) months a total of at least twelve (12) points, based on the

following conditions and point system (approximate dates of each occurrence must

be documented):

Points (each)

a. Urinary tract infection;

4

b. Episodes of bronchitis;

6

c. Streptococcus infection;

6

d. Simple cold;

2

e. Occurrence of pneumonia, severe bums,

12

major surgery, tuberculosis, hepatitis,

meningitis, cancer.

3. Presence of chronic renal disease; cerebral palsy; cardiac disease; cystic fibrosis; thyroid disorders; inborn errors ofmetabolistn; any medical condition that interferes with the ingestion, absorption or uti1ization Qfnutrients and requires a therapeutic diet.

a. Chronic diseases or medical conditions which are directly related to nutritional status ofthe individual must be identified in the documentation.

b. Chronic diseases or medical conditions which are not directly related to, but may affect nutritional status, must be identified by a Competent Professional Authority. Documentation must include a description of how the disease or condition affects nutritional status.

c. Documentation for Lactose Intolerance must contain a list of symptoms described by the Program applicant/participant.

CT-60

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-lO cont'd PRIORITY

4. When using IDV positive status as a Nutritionally Related Medical Condition, write "SEE MEDICAL RECORD" for documentation purposes.

K DIABETES OR HYPOGLYCEMIA

Insulin Dependent Diabetes Mellitus (IDDM), Non-Insulin Dependent Diabetes Mellitus (NIDDM), or Hypoglycemia. Diagnosis and current diet prescription from a physician must be documented in participant's health record.

M MULTIPLEBIRTHS

Delivered two (2) or more infants. Applies to most recent pregnancy only.

N DELIVERY DATE LESS THAN 25 MONTHS AFTER TERMINATION OF LAST PREGNANCY

Document tennination date(s) of past two (2) pregnancies in the participant's health

record.

.

o HISTORY OF.LOW BIRTH WEIGHT INFANT(S)

Woman has delivered infant(s) weighing 2500 gms (5 pounds 8 ounces) or less during most recent pregnancy.

P HISTORY OF INFANT(S) GESTATIONAL AGE LESS THAN 38 WEEKS

Delivered infant before 38 weeks gestation. Applies to most recent pregnancy only.

Q HISTORY OF FETAL OR NEONATAL LOSS

a. Document date(s) offetallneonatal death(s) in the participant's health record. This applies to any loss during the most recent pregnancy. This does not include elective abortions.
b. Neonatal loss is defined as a death(s) occurring to an infant(s) less than 28 days of age.

R GREATER THAN FOUR (4) PREGNANCIES
Woman was pregnant for the fifth or more time. Document multiparity in participant's health record.

CT - 61

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-I0 cont'd

PRIORITY

V BREASTFEEDING AN INFANT AT RISK
Infant is assessed eligible for WIC as a Priority I, II, or IV. A breastfeeding woman and her infant are always placed in the highest priority to which either is eligible. Reciprocal .risk is when one of the two (2) is certified based on the eligibility of the other. Document infant's risk criteria in the space provided on the Women's Certification Form.
X INADEQUATE DIETARY PATTERN
1. Any food group missing based on the Recommended Daily Servings Chart (Attachment CT-24);
2. Failure to meet the recommended number of servings for two (2) food groups;
3. Practice oftwo (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-25);
4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings for one (1) food group.

1, II, IV IV

CT-62

GA WIC PROCEDURES MANUAL FY '96 NUTRITIONAL RISK CRITERIA

Attachment CT-11

PRIORITY

POSTPARTUM, NON-BREASTFEEDING WOMEN

A IRON DEFICIENCY SCREENING VALUE

VI

Hematocrit: less than 36% Hemoglobin: less than 12 gms

B BELOW STANDARD WEIGHT FOR HEIGHT

VI

Weight is less than or equal to 10% below standard weight for height. Refer to Weight for Height Table, Attachment CT-23.

C ABOVE STANDARD WEIGHT FOR HEIGHT

VI

Weight is greater than or equal to 20% above standard weight for height. Refer to Weight and Height Table, Attachment CT-22.

D NOT FOLLOWING RECOMMENDED RATE OF WEIGHT GAIN

VI

Inadequate weight gain during most recent pregnancy based on pregravid weight status. Total weight gain ofless than:

a. 25 pounds ifNormal weight b. 28 pounds if Underweight c. 15 pounds if Overweight Document total weight gain in the participant's health record.

G DELIVERY DATE PRIOR TO 19TH BIRTHDAY

III

H DELIVERY DATE AFTER 35TH BIRTHDAY

VI

CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING, NO PRENATAL CARE

VI

1. Classical clinical manifestations as described in Attachment CT-23. Anyone manifestation is acceptable criterion. Document description(s) of clinical sign(s) in participant's health record.

2. Dental problems severe enough to interfere with mastication and/or have other nutritionally related health implications. Document diagnosis in the participant's health record.

CT- 63

GA WIC PROCEDURES MANUAL FY '96

CODE

PRIORITY

3. Lead poisoning as determined by a positive laboratory test. Laboratory test results must be documented in the participant's health record.

Document date of the test; must have been performed in the previous

six (6) months.

VI

4. Applicant did not have prenatal care during most recent pregnancy.

J NUIRITIONALLY RELATED MEDICAL CONDITIONS

VI

Any disease or condition affecting nutritional status. As defined but not limited to chronic disease, febrile conditions or infections, HIV positive status or parasitic infections.

Guidelines include but are not limited to:

1. History ofparasitic infection in the past six (6) mOJ;lths. Document laboratory test and date in participant's health record.

2. In the past twelve (12) months a total of at least twelve (12) points, based on the

following conditions and point system (approximate dates of each occurrence must

be documented):

Points (each)

a. Urinary tract infection;

4

b. Episodes of bronchitis;

6

c. Streptococcus infection;

6

d. Simple cold;

2

e. Occurrence of pneumonia, severe burns,

12

major surgery, tuberculosis, hepatitis,

meningitis, cancer.

3. Presence of chronic renal disease; cerebral palsy; cardiac disease; cystic fibrosis; thyroid disorders; inborn errors ofmetabolism; any medical condition that interferes with the ingestion, absorption or utilization of nutrients and requires a therapeutic diet.

a. Chronic diseases or medical conditions which are directly related to nutritional status of the individual must be identified in the documentation.

b. Chronic diseases or medical conditions which are not directly related to, but may affect nutritional status, must be identified by a Competent Professional Authority. Documentation must include a description of how the disease or condition affects nutritional status.

CT-64

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-11 cont'd

PRIORITY

c. Documentation for Lactose Intolerance must contain a list of symptoms described by the Program applicant/participant.

4. When using mv positive status as Nutritional Related Medical Condition, write "SEE MEDICAL RECORD" for documentation purposes.

K DIABETES OR HYPOGLYCEMIA

VI

Insulin Dependent Diabetes Mellitus (lDDM), Non-Insulin Dependent Diabetes Mellitus (NIDDM), or Hypoglycemia. Diagnosis and current diet prescription from a physician must be documented in participant's health record.

M MULTIPLEBIRTHS

VI

Delivered two (2) or more infants. Applies to most recent pregnancy only.

N DELIVERY DATE LESS THAN 25 MONTHS AFTER TERMINATION

OF LAST PREGNANCY

VI

Document termination date(s) of past two (2) pregnancies in the participant's health record.

o mSTORY OF LOW BIRTH WEIGHT INFANT(S)

VI

Woman has delivered infant(s) weighing 2500 gms (5 pounds 8 ounces) or less during most recent pregnancy.

P mSTORY OF INFANT(S) GESTATIONAL AGE LESS THAN 38 WEEKS

VI

Delivered infant before 38 weeks gestation. Applies to most recent pregnancy only.

Q mSTORY OF FETAL OR NEONATAL LOSS

VI

1. Applies to most recent pregnancy only. Does not include elective abortions. 2. Neonatal loss is defined as a death occurring to an infant less than 28 days of age.

R GREATER THAN FOUR (4) PREGNANCIES

VI

Woman was pregnant for the fifth or more time. Document multiparity in participant's health record.

CT -65

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-11 cont'd PRIORITY

X INADEQUATE DIETARY PATTERN

VI

1. Any food group missing based on the Recommended Daily Serving Chart

(Attachment CT-24);

.

2. Failure to meet the recommended number ofservings for two (2) food groups;

3. Practice oftwo (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-25);

4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings for one (1) food group.

CT-66

GA WIC PROCEDURES MANUAL FY '96 NUTRITIONAL RISK CRITERIA

Attachment CT-12

PRIORITY

INFANTS

A IRON DEFICIENCY SCREENING VALUE

Hematocrit: less than 34% Hemoglobin: less than 11.4 gms

B BELOW STANDARD WEIGHT FOR LENGTH

On NCHS B-36 month growth chart (see Attachment CT-21), weight for length plot is on or below the 10th percentile line.

C ABOVE STANDARD WEIGHT FOR LENGTH

On NCHS B-36 month growth chart, weight for length plot is on or above the 95th percentile line.

E. BELOW LENGTH FOR AGE

On the B-36 month growth chart, length for age plot is on or below the 10th percentile line. Follow the Child Health Guidelines and the Nutrition Guidelines for Practice to adjust for prematurity. Base WIC certification on non-adjusted plot. Use the adjusted plot for counseling purposes.

F NOT FOLLOWING ESTABLISHED PATTERN OF GROWTH

1. Any documented weight loss. 2. No increase in length in at least a six (6) month period. 3. Deviating from established growth curve by a decrease of one (1) growth channel
at any time in the prior six (6) months. 4. Deviating from established growth curve by an increase of two (2) growth channels
at any time in the prior six (6) months.

Note: Head circumference is an important iridicator of cranial growth deviation and should be checked on infants up to 24 months of age for referral purposes. However, head circumference can not be used as a risk criterion for WIC.

CT-67

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-12 cont'd . PRIORITY

CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL PROBLEMS, LEAD POISONING

1. Classical clinical manifestations as described in Attachment CT-23. Anyone (1) manifestation is acceptable criterion. Document description(s) of clinical sign(s) in participant's health record.

2. Dental problems severe enough to interfere with mastication and/or have other nutritionally related health implications. Document diagnosis in the participant's health record.

3. Lead poisoning as determined by a positive laboratory test. Laboratory test results must be documented in the participant's health record. Document date of the test; must have been performed in the previous six (6) months.

J NUfRITIONALLY RELATED MEDICAL CONDITIONS

I

Any disease or condition affecting nutritional status, as defined but not limited to chronic

:mv disease, febrile conditions Of. infections,

positive status or parasitic infections.

Guidelines include, but are not limited to:

I. History ofparasitic infection in the past six (6) months. Document laboratory test and date in participant's health record.

2. An infant must have at least one (1) point per month oflife, based on the following conditions and point system; approximate dates of each occurrence must be documented (see examples below).

a. Urinary tract infection; b. Episode of bronchitis; c. Streptococcus infection; d. Simple cold; e. Otitis media; f. Occurrence of pneumonia,
severe bums, major surgery, tuberculosis, hepatitis, meningitis, cancer.

Points (each) 4 6 6 2 4 12

Examples:

(I) A 5 month old infant needs at least 5 points. If at two months of age this infant had a cold (2 points); and an ear infection (4 points) at four months of age; for a total of 6 points. This risk factor may be used.

CT- 68

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-12 cont'd

PRIORITY

(2) A 3 month old infimt needs at least 3 points. If at 2 months old this infant had a cold (2 points); for a total of2 points. This risk factor can not be used.

3. Presence of chronic renal disease; cerebral palsy; cardiac disease; cystic fibrosis; thyroid disorders; inborn errors ofmetabolism; any medical condition that interferes with the ingestion, absorption or utilization of nutrients and requires a therapeutic diet.

a. Chronic diseases or medical conditions which are directly related to nutritional status of the individual must be identified in the documentation.

b. Chronic diseases or medical conditions which are not directly related to, but may affect nutritional status, must be identified by a Competent Professional Authority. Documentation must include a description of how the disease or condition affects nutritional status.

c. Documentation for Lactose Intolerance must contain a list of symptoms described by the Program applicant/participant.

4. Infant born to a mother presently using or with a history of street drug9jjmgg~9!)&:ll

5. When using HIV positive status as a Nutritionally Related Medical Condition, write "SEE MEDICAL RECORD" for documentation purposes.
o LOW BIRTH WEIGHT INFANT

Infant birth weight was equal to or less than 2500 gms (5 pounds 8 ounces). Document birth weight in participant's health record.

P GESTATIONAL AGELESS THAN 38 WEEKS

Infant was born at less than 38 weeks gestation. Document weeks gestation in participant's health record.

V INFANT OF A BREASTFEEDING MOTHER AT RISK

I, II, IV

Mother is assessed eligible for WIC as a Priority I or IV. A breastfeeding woman and her infant are always placed in the highest priority in which either is eligible. Reciprocal risk is when one (1) of the two (2) is certified based on the eligibility of the other. Document woman's risk criteria in the "Comments" section on the infant's form.

CT -69

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-12 cont'd PRIORITY

W 1NFANT [UP TO SIX (6) MONIHS] OF A WIC MOTIIER OR MOTIIER

WITH NUTRITIONAL RISK DOCUMENTED DURING PREGNANCY

II

1. Infant of a WIC mother who participated during pregnancy. (Automatic risk).

2. Infant of a woman whose health record documents a nutritional risk during pregnancy that would have made her eligible for WIC in Priority I. Participation during pregnancy is not required. Document woman's nutritional risk during pregnancy in "Comments" section on the infant's form. Criteria can be used for initial certification until the infant is six (6) months of age. May not be used for initial certification after six (6) months of age.

"X INADEQUATE DIETARY PATTERN

IV

1. Any food group missing based on the Recommended Daily Servings Chart (Attachment CT-24);

2. Failure to meet the recommended number of servings for two (2) food

IV

groups;

3. Practice oftwo (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-25);

4. The practice of one (I) inappropriate food practice and the failure to meet the recommended number of servings for one (1) food group;

5. Consuming less than the recommended amount of iron-fortified or prescription formula for infants, or consuming a low-iron formula without a prescription! physician's recommendation.

CT-70

GA WIC PROCEDURES MANUAL FY '96 NUTRITIONAL RISK CRITERIA

Attachment CT-13

CHILDREN

PRIORITY

A IRON DEFICIENCY SCREENING VALUE

III

12-23 months of age: Hematocrit: less than 34% Hemoglobin: less than 11.4 gms

24 months-5 years of age: Hematocrit: less than 36% Hemoglobin: less than 12 gms

B BELOW STANDARD WEIGHT FOR LENGTHIHEIGHT

III

Weight for length/height plot is on or below the lOth percentile line. For recumbent length measurements use NCHS B-36 month growth grid; for standing height measurements use NCHS 2-18 years growth grid (see AttachmentCT-21).

C ABOVE STANDARD WEIGHT FOR LENGTHIHEIGHT

III

Weight for length/height plot is on or above the 95th percentile line. For recumbent length measurements use NCHS B-36 month growth grid; for standing height measurements use NCHS 2-18 years growth grid.

E BELOW LENGTHIHEIGHT FOR AGE

III

Length/height for age plot is on or below the 10th percentile line. For recumbent length measurements use NCHS B-36 month growth grid; for standing height measurements use NCHS 2-18 years growth grid. Follow the Child Health Guidelines and the Nutrition Guidelines for Practice to adjust for prematurity. Base WIC certification on non-adjusted plot

F NOT FOLLOWING ESTABLISHED PATTERN OF GROWTH

III

1. Any documented weight loss.

2. No increase in length/height in at least a six (6) month period.

3. Deviating from established growth curve by a decrease of one (1) growth

III

channel at any time during the prior six (6) months.

CT -71

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-13 cont'd

PRIORITY

4. Deviating from established growth curve by an increase oftwo (2) growth channels at any time during the prior six months.

Note: Head circumference is an important indicator of cranial growth deviation and

should be checked on children up to 24 months of age for referral purposes. However,

head circumference can not be used as a risk criterion for WIC.

.

CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING

ill

1. Classical clinical manifestations as described in Attachment CT-23. Anyone manifestation is acceptable criterion. Document description(s) of clinical sign(s) in participant's health record.

2. Dental problems severe enough to interfere with mastication and/or have other nutritionally related health implications. Document diagnosis in the participant's health record.

3. ~d poisoning as detennined by a positive laboratory test. Laboratory test results must be documented in the participant's health record. Document date of the test; must have.been performed in the previous six (6) months.

J NUTRITIONALLY RELATED MEDICAL CONDITIONS

ill

Any disease or condition affecting nutritional status. As defined but not limited to chronic disease, febrile conditions or infections, HIV positive status or parasitic infections. Guidelines include but are not limited to:

1. History ofparasitic infection in the past six (6) months. Document laboratory test and date in the participant's health record.

2. In the past twelve (12) months a total of at least twelve (12) points, based on the

following conditions and point system (approximate dates of each occurrence must

be documented):

Points (each)

a. Urinary tract infection;

4

b. Episode of bronchitis;

6

c. Streptococcus infection;

6

d. Simple cold;

2

e. Otitis media;

4

f Occurrence of pneumonia, severe bums,

12

major surgery, tuberculosis, hepatitis, meningitis,

cancer.

CT-72

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-13cont'd

CODE 3.

PRIORITY

Presence of chronic renal disease, cardiac disease; cerebral palsy; cystic fibrosis;

thyroid disorders; inborn errors ofmetabolism; any medical condition that interferes

with the ingestion, absorption or utilization ofnutrients and requires

a therapeutic diet:

III

a. Chronic diseases or medical conditions which are directly related to nutritional status of the individual must be identified in the documentation.

b. Chronic diseases or medical conditions which are not directly related to, but may affect nutritional status, must be identified by a Competent Professional Authority. Documentation must include a description of how the disease or condition affects nutritional status.

c. Documentation for Lactose Intolerance must contain a list of symptoms described by the Program applicant/participant.

4. When using HIV positive status as a Nutritionally Related Medical Condition, write "SEE MEDICAL RECORD" for documentation purposes.

X INADEQUATE DIETARY PA1'1'ERN

v

I. Any food group missing based on the Recommended Daily Servings Chart (Attachment CT-24);

2. Failure to meet the recommended number of servings for two (2) food groups;

3. Practice oftwo (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-25);

4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings for one (1) food group.

Z POSSIBILUY OF REGRESSION IF REMOVED FROM TIIEPROGRAM

III, V

Possibility ofregtession is the likelihood of returning to a nutritional risk that was used during the most recent certification period in the current WIC status (i.e. child status). This category is only to be used when there are no other nutritional risk criteria present. Use is at the discretion of the CPA. Document reasons for possibility of regression in the "Comments" section ofthe WIC Assessment/ Certification Form. Regression cannot be used for the initial certification period. Priority remains the same as most recent certification priority.

CT - 73

GA WIC PROCEDURES MANUAL FY '96

AttachmentCT..14

NOTICE OF TERMINATIONIINELIGmILITYIWAITING LIST FORM

-Di-rH-iR

c...p.~"I'-~
........oi"""'_-WlC""'NOTICE OF TERMINATION / INEUGIlllUTY I WAfTING UST
'Dllt.'ROf"nc.

$-_

rmMlNAtlOH / lHUIGI8IUTY SfCROH,

"'''WlC o You "'" oigi>le ''''''''''"_

o You b<Oog """"""'" " - "'" WlC

""""""_

_ _ ha\e an ino:lme that is too Ioql for the WIC Progran.

_ _ _ ....... _ _ do"",o.e"""'"""...-lby ol-G W1C .......... ""'"",,,",,",._o<~_d'*l

tM(S),.......

_ _ do not hc:M= ClI tnedical / nutritional health pob&ctn. _ _ &l .......tum 10"'" '"""' '" """ _ ~on

_ _ did not pa~ 'fOJl food ~ fer t-...o {2} monft,s. You 'ld be ~ OC"I _ _ _ _ _ _ _ _ (dat<~

Qlt- _ _ had are not ~ to K'f'l"e postpartum ilOlt-beosttieedit19 women.

(dat<~

WSI'HSK)N SECTION,

o You ... b<Oog.....,ended"- "'" W1C .......... fa< -(3)""'""" ~)'OUbo>loe"'" """"""'"

WlC""""""'n.oIe(.)

_

WAITlftG U5T SECTION,

o Yo-J ae ~ pIoc:ed en c woiting kt. n..rd. eft' not ~ to serYe pnorityfecs)

~ You ore

in piority



You may st'II ~ nutritional education and othec' servioe:s pcMded by the Heokh Deportment.

f "'" noed ~ 0< -Ad "" 10 &.om ol-G _ oddo= bolow:

plecoe contod "'" WIC P.ogam at "'"

FAlA: HEARING SECTION:

You hcnooe 0 right to Cl foir heoring if )IOU do not ~ with the teOSOn for your ~ / ineGgOIity Ol" ....-cmng

'" pIooomont A _ _ 10< 0 fo< .............. be onode witf,;n 60 dey< of .... dote of '"" no"'.. fo< .........

_ _ >hould be ~ 10:

_( .........

- " - 0 . 1hG .. on God Oppom.rity Pnogoam. f ,.... - . . ,.... ..... been _

""'""" beaouoo of __ """'.

_

...... __ ... O<~-~Io""'s.c_yof~

C. 202S0.

(BACK)

NUTRITIONAL RISK PRIORITY SYSTEM

I. Priority l'

Pregnant women., breastfeeding women and infants with a nutritional need. Tnis need is determined by measuring height/weight, laking a blood test and medical history.

Priority 2:

Breastfeeding women who do nOt qualify under Priority I, but are breastfeeding Priority 2 infants.

Infants up to six (6) months of age bom to women who were Program

panicipants during their prcgnancy.

.

Priority 3:

Infants up to six (6) months of age born to women who were not Program participants during pregnancy but had a nutritiorW need.
Children with a nutrilionaJ need. This need is determined by measuring height/weight, taking a blood test and medical history

4. Priority 4: 5. Priority 5: 6. Priority 6:

Postpartum teenagers who are not breastfeeding.
Pregnant women, breastfeeding women and infants with a nutriti<)Oal need
because ofpoor diet orMmClCSSrllligranq' Status.
C~i1dren with a nutritional need because of poor diet or hOmdess/niiSrancY
status.
Postpartum. non-breastfeeding women with a' 'nutritional need, or hO'thelesslmigrancy status and homeless/inigrant posipartumrion~bieastfeeding teenagers.

CT-74

-II")
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~
<f!:

WIC PROGRAM
STAMP

032651

nATE Of OEOROI" OE'ARUUNT Of HUMAN AnOURcn VERIfiCATION OF CERTIFICATION CARD

it

'."TIC1'ANtIPARENT/OUARDIAH SIGNATURE

SIGNATURE OF Wit OFFICIAL

PAATtCI1ANT CERTIFICATION IH'ORMATtON
PA"TlCIPANT NAME DAT( Of elRTH CERTIfiCATION OATE

I. O.HUMBEf' OATE Of INCOME TAKEN MEDICA1. DATA DATE

DATI CERTIfiCATION EXPIAU

NUTRITIONA1. RISIC CRlnRIA

AUntOf'lllO ,P10XY 1I0NATURE

COUNTYICL1NIC

HEIQH' fOOD PACKAGE

P"IORITY

WEIGHT IOCOAT,.

HIMATOCRIT DELIVERY DATE

II tlLlPttoHI NUMIER

CLINIC ADORUS

II")
r--

~
~

THIS CARD MUST 8E ACCEPTED BY ALL STATE AND LOCAL AGENCIES AS A WIC PROGRAM VERIFICATION OF CERTIFICATION UNTIL EXPIRATION DATE.

t-< U

f:

______________ PARTICIPANTS RIGHTS

_

S'",dtrd, '01 participation In tN p'OO',m Irt the II"" 'or .v.ryone 'Iglfdleu of llel, color,

~
~
~
00
~
~

r-.
o
oz uE:
~i

ur-;l ~,

f\'tigntl origin, Ie. or hlt1dic,p.

You m.y ,ppul ."y dtchion m.dI by thl loc,1 tQtncy r,glrding your p.nicipltion in the "OVum.

'rtThe locll toQIncy will mIlt, hnhh uNioli and nutrition 'duc,tion n.i1,bl. to YW ."d you encour.d to ptrtici~tt in thet. JfNicel.

____________ DERECHOS DE PARTICIPANTES

:.

_

'at lM norm. PI"I, p."'iCip'li~to ,I pro9!',m, Ion mhm. PIf'lod" I. penon" no
impot" I, r,te, color, ,llug.r de nKimicnl0, 'dad, HllO 0 fitleo 0 mcnhllmpedimen10.

lkltd putdt epe1lr II OttiliOn 10mi'd, por I. 19tneialoce! con '"peel0, IU p,niCiPtt;:i&'
.n .1 "09'Iml.
lI,..nd.loetI "rttllt~ pit, ulM I, dilponibilidld eN MrvidOi dt I"ud y cit eduuc:i6n tn l",nlOi de nutritiOn YIf flcomitnd. qut lid. h'Ol uto de 'I1011trvicios.

' ..... JJU I...... , .....1

I,.A$T OATE OF VOUCHER IUUANCE

LAn DATE Of NUTRITION OUCATI~

' ..... Utl lilt.. 1011'

~

(FRONT)

(BACK)

~
~
~

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~
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~
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~
~
~
tI.)
~
u~
~
~
u
~
~
~

GEORGIA WIC PROGRAM VOC CARD INVENTORY LOG

District

_

Clinic'--

_

CARD NUMBERS (RECEIVED)

CARD NUMBERS (ISSUED)

PARTICII'ANTS NAME

SIGNATURE

CITY

(I'RlNT)

PARENT/GUARDIAN/CARETAKER STATE

WIC 1.0. NUMBER

NUMBER OF
CARDS ON HAND

DATE

STAFF INITIALS

\t0-
f-;
U

NOTE: A Physical Inventory of VOC Cards must be perfonned by the local agencies and clinics monthly. One staff member must conduct the inventory (initial the Log) and a second staff member must verify the accuracy of the inventory (initial the Log also).

t"--
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~
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~
-~
U ~

~

CLINIC NAME

LOCAL AGENCY VOC CARD INVENTORY LOG

VOC CARD NUMllERS ISSUED

NUMllER OF VOC CARDS ON I-lAND

NUMBER OF VOC RECEIVED FOR THE STATE

NAME OF STAFF WHO ISSUED VOC CARDS

DATE

INITIALS (CPA)

INITIALS (CPA)

l' l'
ur--

,

GA WIC PROCEDURES MANUAL FY '96 MEASURING LENGTH

Attachment CT-18

~:
Birth to 24 months 24-36 months, ifproper position to measure stature cannot be achieved or with children less than 35 inches in stature.

MateriallEguipment:

Recumbent length board with fixed headboard and movable footboard, both at right angles Marked in increments of 1/8 inch 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 ofthe 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.

CT -78

GA WIC PROCEDURES MANUAL FY '96 MEASURING HEIGHT

Attachment CT-18 cont'd

~:

Children two (2) years of age and older who are at least 35 inches in stature Adults

NOTE: Once measurements are started with child standing, all subsequent measurements must be done standing.

Material/Equiprnent:

Wall mounted or portable stadiometer or.metal measuring tape mounted on wall. A right angle head board. Marked in increments of 1/8 inch.

Procedure:

1. Remove all bulky clothing, head and foot wear.

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 head board 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 remeasure until two (2) readings agree within 1/4 inch.

7. Record the second reading promptly.

CT-79

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-18 cont'd

MEASURING WEIGHT

~:

Infants and very young children up to 35 pounds

MaterialslEquil'ment:

Scales with beam balance and non-detachable weights. Scales must be calibrated yearly (see Attachment CT-18)

Procedure:

1. Check scales at zero (0) position. With weights in zero (0) position, indicator should point at zero (0). Ifnot, use the adjustment screws to move adjustable zeroing weight until the beam is in zero (0) balance.

2. Remove shoes and clothes. Remove diaper ifwet.

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 112 ounce.

7. Record the second reading promptly.

CT-80

GA WIC PROCEDURES MANUAL FY '96 MEASURING WEIGHT

Attachment CT-18 cont'd

~:

Children who can stand unattended by an adult Adults

MaterialslEquipment:

Standard platfonn beam scale with non-detachable weights Marked in increments of at least 1/4 pound or 100 grams Scales must be calibrated yearly (see Attachment CT-18)

Procedure:

1. Check scales at zero (0) position. With weights in zero (0) position indicator should point at zero (0). Ino1, 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.

CT - 81

GA WIC PROCEDURES MANUAL FY '96 EOUIPMENT MAINTENANCE
1.

Attachment CT-19

Georgia Department ofAgriculture Fuel and Measures Division Agriculture Building, Room 321 Capitol Square Atlanta, Georgia 30334 (404) 656-3605, GIST 221-3704
2. A yearly calibration of centrifuges is also recommended for proper usage. 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.
3. It is recommended that hematological equipment be checked for accuracy (balanced) according to a regular schedule, based on usage. Several methods are available for checking equipment. These methods include:
A. Spinning one (1) sample of blood twice:
I. Obtain a blood sample and centrifuge it. 2. Read the hematocrit value. 3. Spin the same blood sample a second time. 4. Read the hematocrit value. 5. Ifthe two (2) value readings are the same, the centrifuge is packing/spinning
the red blood cells sufficiently and the centrifuge is calibrated. 6. Ifthe two (2) values are.different, the centrifuge is not calibrated and needs to
be serviced.
B. Spinning two (2) tubes of blood collected from the same person, and centrifuging both samples at the same time. Values obtained should be approximately the same.
C. Running a standard solution and obtaining an acceptable reading for that solution.

CT - 82

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-19

CT-83

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-19 cont'd

IRlMmeST
~! lilR~ ~

I: ~lI&.li%mltl~ll~ ii! _1R:4j __~.
gj

~~;

CT- 84

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-19 cont'd

CT- 85

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-19 cont'd

~@)mjjj!s ;.J1!ftffimm\f@!fiIW ~lm4Arall,~B.~

CT- 86

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-19 cont'd

CT- 87

LICENSED SCALE MECHANICS

Licensed as of 1/13/95

~

COMPANY

LOCATION

CLASS

TELEPHONE

0
(,)

AAA Scales & Systems

3232 Harmony Ch Rd Geinesville 30507

1234

706 532-2316

.0...\. I

Advanced Computer Sales Albany Scale Co.

1702 N Slappey Blvd Albany 31701 PO Box 871 Albany 31702

1 1234

912883-2398 912436-2351

E-< U

Albany Typewriter Exchange

PO Box 724 Albany 31703

1

912 436-6541

~ ]

All American Business Machine

739 McCalie Ave ChaU TN 37403

I

A & MCD Scale and Equip

4248 Hwy 25 N Hephzibah GA 30815

12

American Eagle Equipment Co,

PO Box 30056 Knoxville TN 37930

I

615 624-7843 80084-0836 615 588-8979

(,)
~

American Standard Scales

PO Box 216 Powder Springs 30073

1234

404943-8455

-<

American Weighing Systems Atlanta EquiplMiddle GA Scale

PO Box 328 Oakwood 30566 1345 Capital Cir NW Lawrenceville GA 30243

1234 1234

404532-1800 404 995-7554

Atlanta Scale Inc.

9999 Tara Blvd Jonesboro 30237

1234

404477-7052

Bankhead Enterprises

1080 Bankhead Hwy Atlanta 30318

1234

404 894-7923

Bannex Corp

5755 Hoover Blvd Tampa FL 33634

1

813884-2500

Berkel Inc.

3095 Presidential Dr. Suite D Atlanta 30340

I

404455-0795

Bi-Lo Inc.

Drawer 99 Mauldin SC 29662

I

803 234-183 I

Birmingham Toledo Inc.

# 3 2nd Ave N Birmingham AL 35120

1234

205 328-0904

Brewer Scale Ser

PO Box 714 Tucker GA 30085

12

404 934-5361

Bulloch Scale Ser Capitol Business Equipment Inc.

Rt 3 Box 146 Statesboro GA 30458

12

675 S McDonough St Montgomery AL 36104

1

912587-5464

00

205 265-8903

00

gIe..

Cardinal Scale Mfg. Co. Carolina Scales Inc.

1452 Kelton Dr SI. Mountain GA 30083 PO Box 8233 Co1umbis SC 29202

1234 1234

404 296-5400

E-<

800277-2439

U

~

Cash Register Exhange Inc.

1501 SI. Luke SI. Augusta GA 30904

1

Columbus Sotre Equipment Co.

1101 6th Ave Columbus GA 31901

1

404724-1747 404 323-5691

~"'"

Conceptual Systems Corp Cunningham Scale Co.

28 Rutledge St Nashville TN 37210-4287 1911 Hampton Ave Augusta GA 30904

123 1234

615 726-0001 404 738-5534

Z
~
00

Daley William J Assoc Data Cash Register Dataserv Inc.

PO Box 19060I Altanta GA 31119

12

10181stAveColumbusGA31902

1

5002 N Royal Dr Ste A Tucker GA 30084

1

404451-2411 404324-2472 404 270-1730

~
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Delta Scale Co. Delta Scele of GA Inc. Dickey Scales Inc.

5201 F Brookhollow Pkwy Norcross GA 30071 Rt 2 Box 136-1 Milan GA 31060 7775 Remona Blvd Jax FL 32221

12347 12347 1234

404 263-9535 912362.4676 800275-0234

fi;l

Dickey Scales Inc.

3009 N Slappy Blvd Albany GA 31701

12345

912888-1600

Co)
0
~

Dixie Balance & Scele Co. Dixie Cash Register Co.

1929 Moore Rd Augusta GA 30906 PO Box 736 Albany GA 31702

12347 1

404 793-1183 912 883-5900

~

Dutch Quality House

PO Box 2397 Gainesville GA 30503

12

800241-3100

.C.o..)

East Tennesseee Scale Works

10000 Martel Rd Lenoir City TN 37771

1234

404 446-9000

~
~

Fairbanks Scales Fairbanks Scales Fairbanks Scales

5970 E Unity Dr Norcross GA 30071 AugustaGA ColumbusGA

1234 1234 1234

Fairbanks Scales

AJbany

1234

Federal Express

1797 NE Expy Atlanta GA 30329

12

404728-5200

Federal Express

2770 Gunter Park Dr Montgomery AL 36109

1

205272-4127

Federal Express

520 Airport Rd Chau TN 3742 I

12

6 I5855-6992

Federal Express

3401 Commonwealth Blvd Tallahassee FL 32303

I

904575-8600

Fieldale Farms

PO Box 558 Baldwin GA 3051 I

12

404778-5100

""c::l
1::
-u0
0\
I

Fieldale Farms Corp Gainesville Scales Inc. Garys Mechanical & Elect Georgia Scale Co

Hwy 60 North Murrayville GA 30564 915 Ridge Rd Gainesville GA 30501 PO Box 144 Commerce GA 30529 3475 Old PetersburgRd Augusta GA 30907

I 1 12 12347

706 534-7373 404 536-7962 404335-4591 706855-1 I II

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G FISer Inc. Gold Kist Engineering Greenv ille Scale Co.

Rt 1 Box 614 Lenox GA 31637 PO Box 340 Valdosta GA 31603 149 Landmark Dr Taylors SC 29687

12 23 123467

912549-7191 912244-7546 803 244-4723

~
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Hobart Corp Hobart Corp

3904 N Peachtree Rd Chamblee GA 30341

1

13 West Gate Blvd Savannah GA 31405

1

404458-2361 912236-0004

~

Hobart Corp Hobart Sales & Ser

PO Box 22403 ChaU TN 37404

1

622 Flint Ave AlbanyGA31701

1

615 899-3366 912436-7105

Hobart Sales & Ser

423 Crawford Avenue Augusta GA 30904

I

404733-0950

Hobart Sales & Ser

PO Box 4380 Columbus GA 3 I904

12

404327-7547

Hobart Sales & Ser

PO Box 3282 JAX FL 32206

12

904356-1376

Hobart Corp

3186 Mercer Univ Dr Macon GA 3 1204

12

912746-5365

Hormel Co Geo A

3367 Montreal Ind Way Tucker GA 30084

123

404 939-4880

Hot Lanta Scale Co

PO Box 43666 Atlanta GA 30336

1234

404 346-0400

Howe Richardson Inc.

4030 Poole Rd Winston GA 30187

1234

404 942-9944

Industrial Scales & Systems Industrial Scales of GA

484 McBrien Rd Chait TN 37412 PO Box 46 Mableton GA 30059

1234 1234

615499-2210

0\

00

404941-8879

I

\D
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Industrial Scales Service IBM Corp

300 E End Blvd S Marshall TX 75760 PO Box 19200 Jax FL 32203

1234 I

903 935-3027

l-

904 390-6700

U

G...:
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IBM Corp IBM Corp IBM Corp

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IBM Corp

Two Union Sq Tallan Bldg Chau TN 37420

I

688 Walnut St Macon GA 31201

1

2743 Perimeter Pkwy Bldg 100 Augusta GA 30910 1

1276 Jessie Jewell Pkwy Gainesville GA 30501

I

615755-3500 912738-3163 404868-3000 404 536-2071

Z

IBM Corp

450 Mall Blvd Savannah, GA 30406

1

912351-2105

~

IBM Corp IBM Corp

PO Box 7128 Columbus GA 31901

1

2425 Westgate Blvd Albany GA 31707

1

404571-3000 9 I2 434-4520

00
~

J H Harvey Co. KPS Sales

PO box 646 Nashville GA 31639

1

1719 Brandy Woods Trail Conyers GA 30208

7

912686-7654 404 922-9605

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~ ~

Kroger Co Kroger Co

PO box 105520 Atlanta GA 30348

1

Brunswick GA: Contact Atlanta Office

1

404 209-6630 912267-0320

Co)

Kroger Co

Augusta GA: Contact Atlanta Office

1

404 209-6630

~
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Lab Tech Inc Mar-Jac Processing Inc.

PO Box 3303 Marietta GA 30061

7

PO Box 1017 Gainesville GA 30503

12

404422-3305 404 536-056 I

~ ~
~

McDonald Scale Co. Middle GA Scale Mid South Data Systems Mid South Data Systems Mid South Data Systems

4295 Cromwell Rd Ste 260 Chait TN 37422-2284 2901 JoycliffRd Macon GA 31211-2800 Duluth GA Contact: Asheville NC 780 Hendersonville Rd Asheville NC 28803 5 Artillery Rd Taylors SC 29687

1234 1234 1 1 1

615 899-5801 912743-5544 704274-4251 704274-4251 803244-7051

NCR Corp

3731 Northcrest Rd Atlanta GA 30349

1

404 936-6502

NCR Corp

130 Conway Dr. Suite G Bogart GA 30622

1

404 548-9097

NCR Corp

1220 W Wheeler Pkwy Ste F Augusta GA 30909

1

404863-6661

NCR Corp

106 Shoppers Way Brunswick GA 31520

1

912 265-6548

NCR Corp

1000 Business Ctr Dr Ste 30 Savannah GA 32256 1

912651-7450

-0
1::
0

NCR Corp NCR Corp

506 45th St Bldg B Suite 8 Columbus GA 31904

I

106 East 8th Street Rome GA

I

404324-7347 404291-2648

(,)

NCR Corp

736 Riverside Dr Macon GA 3 I 20 I

1

912743-3509

.0....\.

Palmetto Scale Service

PO Box 324 Irmo SC 29063

1234

803781-2020

?

Peach State Scale Works

PO Box 42407 Atlanta GA 30311

12

404763-0092

U

Phillips Scale Service

5390 Frances Ave St Mountain GA 30087

12

404381-2203

1:!
Q)

Postec Inc

2250 Northwest Pkwy Ste D Marietta GA 30067

1

404422-7609

~ ~

Raingo Scale Service Reliable Cash Registers Rich Sea Pak Corp Rite Weight Inc.

PO Box 43 I Rockford AL 35136

234

PO Box 183 Rome GA 30161

I

200 Glyndale Dr Brunswick GA 31522

I

3802 Irvinda1e Rd Duluth GA 30136

I

205 377-4924 706 295-5652 9 I2638-5000 404476-8500

S & S Scale Service

Rt 2 Box 136 Byron GA 31008

1234

912956-2410

Scale & Automation Systems

2299 Brockett Rd Tucker GA 30084

12

404 939-7922

Scale Data Systems Inc.

3772 Pleasantdale Rd Suite 190 Atlanta GA 30340 I

404908-9616

Scale Man

4315 Highsmith Rd Gainesville GA 30507

I

404535-2019

Scale Systems Inc.

6269 McDonough Dr Norcross GA 30093

1234567

404 449-7770

Scale Systems Inc.

472 Flowing Wells Rd Augusta GA 30907

1234

404 855-54 I7

Scale Systems Inc.

585 Lower Poplar St Macon GA 3120 I

1234567

Scale Systems Inc. Shamrock Scale Inc

1212 Metro Dr Columbus GA 3 I907 PO Box 931 Dalton GA 30722

1234567 1234

404 568-3508 706226-0977

0 0\

\D ~
~

Shamrock Scale Inc Sisson Scale & Equipment South GA Scales Technology Service Solutions

9402 Hwy 92 Ste 102 TampaFL 33610 123 Prosperity Dr Savannah GA 31408 PO Box 999 Ray City GA 3 I545 5555 Oakbrook Pkwy Ste 180 Norcross GA 30093

1234 1234 12 I

8 I 3 626-9225

f-<

912966-2114

U

800425-5678

404447-5390

;"-:"<J"
Z

TGA Scale Supply Inc. Thomas Concrete of GA Toledo Seale Co

PO Box 23001 Chatt TN 37422 1745 Phoenix Blvd Ste 480 Atlanta, GA 30349 3658Y, Buena Vista Rd Columbus GA 31906

1234 12 1234567

615 894-4657 404447-4841 800 282-9721

~

Toledo Scale Co Toledo Scale Division

6148 Hawkinsville Rd Macon GA 31206

1234

5680 Oakbrook Pkwy Ste 175 Norcross GA 30093 12345

912781-6126 404447-1401

OCJ
~

Turner Scale Ser VanZant Enterprises Inc. Wayne Fann/Continental Grain

581 B George Todd Dr Montgomery AL 36117 6008 Minneola St Panama City FL 32404 PO Box 69 Pendergrass GA 30567

1234 7-Belt 12

205 271-3232 904871-4544 404693-2271

~
riI
Ug

Weighing & Control Service Weigh-Systems Whitaker Scele Service

PO Box 2374 Brarrdon FL 33509-2374 154 Brond St Tallnpoosa GA 30176 Rt 2 Box 753 Broxton GA 31519

7-Belt 1234 1234

813 689-5785 404574-8253 912375-4804

~
U....
~

Wiggins Scale Co Wilde Scale Service Williams Bros/Blue Circle Wingfield Scale Co

1005 Hemphill Ave Atlanta GA 30318 PO Box 150 Lula GA 30554 1800 Pkwy Place Suite 1100 Marietta GA 30067 2205 Holtzclaw Ave Chatt TN 37404

1234 1234 7 Hopper 1234

404 872-4994 404677 -3286 404 499-2800 615698-3346

~

Zartic Inc Zartic Inc

808 West Ave Cedertown GA 30125

12

438 Lavendar Dr Rome GA 30 I61

12

404748-2700 404 234-3000

GA WIC PROCEDURES MANUAL FY '96 ACTION CODE DEFINIDONS;

Attachment CT-19 cont'd

Action 1: Approved - The scale is performing and weighing within legal tolerance.

Action 2:

Rejected - The scale is not performing or weighing within legal tolerances. The scale should be repaired or serviced by a registered scale repairman.

Action 3:

Condemned - The scale is not legal or is in such bad shape it can not be repaired. The scale will have to be replaced.

Action 4: Tied down - The scale is actually tied down to avoid use.

Action 5: Out of Use - Self explanatory.

Action 6: Sold - Self explanatory.

Action 7: No Test - Self explanatory.

Out of Tolerance: Not weighing correctly (scale needs to be serviced by company).

Delete:

The scale is no longer there; no longer being used.

I
I

CT - 91

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-20

INSTRUCTIONS FOR USE OF PRENATAL WEIGHT GAIN GRID (Form #3059)

1. Record applicant/participant's name.
2. Use "Weight for Height Table" (Attachment CT-23) to determine if the applicant is Normal Weight, "10% or more Below Standard Weight for Height" or "20% or more Above Standard Weight for Height, using pregravid weight." Select for use 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 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 weeks of gestation.
b. Using the gain (or loss) in weight from the pregravid weight baseline and the gestational weeks (this visit) place an X on the point at which these two (2) lines meet.
c. Ifthe patient does not know her pregravid weight, or ifthe weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated 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 weeks of gestation should be plotted on the grid.

CT-92

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-20 cont'd

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

WEIGHT FOR HEIGHT TABLE FOR DETERMINING WIC ELIGIBILITY (SQurce:MettopeJiI"n (jfeln$<J'IIt><:.ee<:>mp.tny.19s:J.,

....09111

,~
Unoen.etgt\l

"'9~(srl

101

.c'10M (Sll"1

"I'l1M (SS,

sOM (60")

112-126

S"-CSt,

110

115129

S'2~(62MI

112

S'3R (6:n

5" "-C6n

5'5'"(65")

5'6'"(66-)

123

S'T"(6r)

126

118-132 121-13$
1271<11 130_144 133_1.(7

""'''"""".".

S'e-C68J

129

136150

m

5"9-(69"}

131

S',O'"{7o-)

139-153

',,".,

;:m:: 32

:u:':O~n--:~h~:':nO~

30

mote ~jghl. 2O"JIoo< mort! 2S
O""'tweI9'I1.O<'ca,ry~nglMns

""
24

Height in inches (without shoes)

_ 22
,.20

Weight History

16

(if not recorded in chart) 14

Ir- :OA:TE E~=WE+IG~HT q 12

Pfegrnid

10

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

NAME

_

,. 0

,4

.. I---+--~ -2 1 -8 f:.. -10

"...".
10
2 4 6 a 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 4 42
Weel\:sof Ptegnancy
Sou,e..: A,ilona oepl. of Healltl $e<v;ce:; AOHSIFHSIONSIN17A - F'\.evise<l9t'31

CT-93

GA WIC PROCEDURES MANUAL FY '96

AttachmentCT-20 cont'd

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT

WEIGHT FOR HEIGHT TABLE
FOR DETERMINING WIC ELIGIBILITY (So<Pee:AA~I'(jPOlililn !.ire InS<trllr>Ce CompalrY. 1983.1

~h1

,~
U_~I

'1'9"'(Sn

""0"'(58,
C'11~(SS'1 S"O~(60"J
5"-(61,

.. ,,

05'2"(62,

''''

5'3-(63/

S'4"(fiolq

SS-fGn

121

5"6""(6OJ

123

121135 124-138 127-141 13014C

"'''""".

S-T(67'j 5'8"'(68"1

126 129

13fi-15O

m'"

S'9-(~'

131

139153

m

S'10"(7lr1

1<12_156

'"

32

Plot_i9nt Sla,n on nO'm&1

eurvoe unless wo..... n is 10'10 Of 30

mo~ u1'>dc<weiglll. 20"0 Of more

-.-igI'U. oreanyitlg twins

2S

2G

Height in inches (without shoes)

2'
22 _
20
18

Weight History

16

(if not recorded in chan) 14

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT
NAME

f----+---l 2
. ' -_ _---'-_ _.....J ..
~ -a
~ -10

24

,...-.2
6al0121416'S~~~~~~~M~~~~ WeeksofPregnaney

Sour<:e' A,ilona ()epl. 01 Health se....i<:6 AOHS/FHSlONSf/llt7A - Re.'$ed 9191

CT-94

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-21

DIETARY ASSESSMENT

Each district must have an approved form and/or method for the purpose of performing a dietary assessment. The form and/or written instructions for the method must be submitted to the Office ofNutrition for approval. Any subsequent change(s) in the form and/or method must also be submitted to the Office ofNutrition for approval.

Diet assessment forms and/or methods are evaluated by the Office of Nutrition usiJig the following criteria:

1. Space for the signature and title of the professional, and the date of the diet evaluation.

2. Space for a food frequency and/or a 24-hour recall.

3. A method for documenting inappropriate food practices (see Attachment CT-26).

4. Evidence that the Recommended Daily Servings Chart is the basis for determining missing food groups and failure to meet recommended number of servings (see Attachment CT-25).

5. A method for determining (for infants) the amount of iron-fortified formula consumed..

6. A method for documenting poor dietary pattern.

CT -95

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

1. Select the appropriate chart for sex and age ofthe 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 birthdate.

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:

Date of Measurement Birthdate Child's Age

Year Month

1981

4

-1975

~

5

8

or 5-3/4 years

Day
21 -10 11 days

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. There are two (2) distinct ways to plot growth measurements: interpolation and rounding. Either of these methods is acceptable but they are not interchangeable. Therefore, once the plotting process has begun, it must be continued using the same method in order to achieve accuracy. It is recommended that each district adopt a single method of plotting.

Interpolation Method:

B-36 Month Growth Chart - Calculate exact age (to nearest week) and plot measurement into the space at the point nearest to the age.

2-18 Years Growth Chart - Calculate exact age (to nearest month) and plot measurement into space at the point nearest to the age.

Rounding Method:

B-36 Month Growth Chart - Calculate age to nearest month and plot on the corresponding line.

2-18 Year Growth Chart - Calculate age to the nearest 1/4 year and plot accordingly.

CT-96

GA WIC PROCEDURES MANUAL FY '96 To round off the child's age, follow these rules:

Attachment CT-22 cont'd

0- 15 days

-round off to the previous month

16 - 31 days

-round off to the next highest month

0- 1 month

-round offto the previous whole year

2- 4 months

-round off to 1I4 year

5 - 7 months

-round off to 1I2 year

8 - 10 months -round off to 3/4 year

11 - 12 months -round off to the next whole year

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.

6. To plot the length ofheightlweight chart:

a. Follow a vertical line at the point of the correct length of 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 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 possibly the measured head circumference and mark the point where the two (2) lines intersect.

8. See the Nutrition Guidelines for Practice for instructions on adjusting for prematurity.

CT-97

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GROWTH CHART FOR GIRLS; BmW TO 36 MONTHS OF AGE

GROWTH CHARTS WITH flEFERENCE PERCENTILES FOR GIRLS BIRTH TO 36 MONTHS OF AGE

N_E

_

_00

_

OATEOFIltKTH
--.......

-......

---_
.....

........

.....
a-_

>--.----1-
-t

These charts to recotd ~ ~rowth of the individual chHd were construaed Gv tr~ t~ation" CenUlf' fot' He.th Statistics in ClOllabor4t:on ~ the Center for Disease Control. The charts lire bGed on dctI from the Feb Research Institute. Yellow Springs. Ohio. These dm are
approptlate for young girls in the general U.s. popu(aion.
Their use will direct attention to unusull body size which. may be due to disease or poor nutrition.
Meaurlng= Take all mIIlSUremenu with the child nude or wfth minimel dothina end without shoes. . . . . .,.
length with the child lying on her bac:k. fully extended. Two people ... needed to melSUre recumbent length properly. Use beam baI~ to meesure weight.
Aeoo,dlnt: Mm. take an mNSUmnents end recotd
them on this front pege. Then Itaph ..eh measurement on
the appfOPrilte chat. F"1nd the child", -cae on the hortzont.l
1CIIe; then follow wrtical line from that point to the horizontaf lewl of the(child", measurement (length, Might
orhudcircumferencel. Where the two lines intersect.meke cross marie. with pencil. In GC'lIphing weight for length,
place the cross marie. di~ctfy mow the child', length at

the horizontal MwI of tNr weight:. When. the c:hiid is

meaured l;ain. join the fWW set of Cl'OU marta to the

previous set by straight lines.

IftbI'PNtin;: Many factors influence Growth. The...fofe~

lrowttt dat. annat be used -'one to di~ diMae~ but

they do "low you UJ identify so"", unusu.J children.

e.ch cMct contaftS .. series of curved lines numbend to

show .tected pen:antiles. These refer to the" nnk of

-.sun in trOUP of ,00. Thus~ when cross mar1t Is on

the 95th IMrcentile line of wei;ht for . , it me_ th.c:
only rove children among 100 of die -.-.rong . . one!

sex hive weights gt'Qter thin 1hIt nc:orded. IIup:t the SIt of c:roa marks you hive Just m.k. If

any .... particulldy high or low (for RlmpIe~ Ibove the

95th perctntile or below the 5th plJn:entilel~ you may want

to refer the child to physician. CDmpI:IIl' the most nc:ent

tel of ClOSS mefks with earlier sets for the AmI child. If she

.... c h _ ropidly In poltl1tile ....Is. you may ..... '"

nt.r her to physician. Rapid c:h-.s are less likely to be significant when they occur within the ranc.e from the 25th

to the 75th percentile.

.

DEPA.fn'MENT OF HEALTH. EDUCAT1ON. AND WELFARE,. PUBLIC HEALTH SERVICE HEALTH lItUOOflica AOMINISTIIIlATtOH. "ATIOHAL Cf:HTEIIl. "'Ott HEALTH STATISTICS. AHO CENTER FO. DIKASE: CONTf'.OL

CT-98

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GIRLS FROM BIRTH TO 36 MONTHS

GIRLS FROM BIRTH TO 36 MONTHS

WEIGHT FOR AGE
A,.{~ths)

'8

U

3Q

...+

36 '" "
- 17 I.
T_
.'5

13 28
'2

.- "

I-

1O

~ I

-t-i -+-+--:

16

:--+--j--,~

.-

'--r-i+ -+

H-+' .... .-\-7 .;---+-'-

~-

.: +-~~.

1--+-+1

---+.-; --::- H~

..

_ c . ...;.., ._-l. -'- --+-;_+_+_+_.

_'.. ~_-'-

~-l-'

-'--' ,,-,-

2 .... -l-.

__ -!-;-;--'''-;'- "';.--i--l-+--'-I-i" .;->-;-

. '-"-

"-,-

CT- 99

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GIRLS FROM BIRTH TO 36 MONTHS

GIRLS FROM BIRTH TO 38 MONTHS

LENGTH FOR AGE

A". I"",..",)

in. ()

12

16

U

36

36

t04

40 ~i~~ .,~ ::~~~ :i:'l=, -+--,-

.F~ ~ ::.

'7..J,--~--~.. ~ ...;-::..:.~ :::;:" ::+:
38 ~~~ ';.0 _~:..~ 1':-:~~..

.

- ~"-I----+--"-I=i:-'

'-!.4x~- ,-;z I--- 98
:/":" -htIM :
....+. : ~_~IZ'"'-

.r:-- ~.:.l.-t--
86 84 82 32

22

i: 20 'irI_~-: =-f~~f:J:~. ~
~-Lt~ ::j::;:Ei~"t:"8 I=;
18 ~~=.;_. -~:~tFj:~-:t'i=-

o

6

12

16

A40(monlhsl

611 56
so.
84
52
50

46

30

36

CT - 100

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GIRLS FROM BmW TO 36 MONTHS

GIRLS FROM BIRTH TO 3S MONTHS
HEAD CIRCUMFERENCE FOR AGE

12

30

:..1! I "

:.:.:k

~-.J_ '

I

40 38 15 36 14

:::-;-r' ~,.:

36
-__..
7...
'ot.
1'~
lb. kS 40 18
38 17
38
1~
.... 34 15 32 " 30 13 28
26 12
I 24 11
22 10

,;-;-; +i '" ",'"
'. !..;..i

- ......

-:-. i';'~
.~ '~"'"

.. ;.- ~~ ';.Sl ~ J':
-:: ,..:; ,"

,. 21

23

25

- 60
....

7+":

; .,
:!

'.

'-:-1

Z7

29

31

33

36

;i

70

80

......"

T

37 I

39

in.

.i I 100 em.

WEIGHT FOR LENGTH

CT - 101

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GROWTH CHART FOR BOYS: BffiTH TO 36 MONTHS OF AGE

......e

DATE OF BtATM

--- - o.t,af

..... 'n

GfIOWTH CHARTS WITH REFERENCE PERCENTILES FOR BOYS BIRTH TO 36 MONTHS OF AGE

_ ftECORD. _ _:.-

_

_

..."".

These .charts to ~rd the growth of the individUiI

child were CDnstruc:ted by the NatioNi Center fQr Health

Sutistics in collaboration with the Outter for Dise-se

Control. The dlarts are based on d.. from the Feb

Researd1 Institute, Yellow Springs, Ohio. These ~ are

IPPropriate for young boys in the general U.s. population.

Their use will direct attention to unusual body size which

m-v be due to dise.se or poor nutrition. Measuring: Take .n ~nu with the child nude

or with minimat dothing and without shoes. Measure length

with the child lying on his back fully extended.. Two people

. . needed 10 measure recumbent ~ properly. Use

beam balance to measure weight.

.

Recording: Firtt 'hke III measurements and record

thm'a an this front page. Then graph eech measurement on

the appropriate chut. Find the child's. on the horizontal

ICIle; then follow vertical' line from the point to the

horizontal level of the child', measurement (length, weight

or head circumferencel. Where the two tines interstet. tMke

cross mark with pencil. In graphing tNeight for length,

place the cross mark directly above the d1ild's len;th at

the horizontal leftt of his weight. When the c:hild is

measured again. join the new set of cross marks to the

PRVious set by st(light tines.

'

lautrpnting: Many Rctors influence growth. Therefore.

growth UtI annat be used "one to diagnose d'tsee. but:

they do allow you to identify some unusuel children.

Each cNrt contains I series of curved lines numbem to

show selected percentl"tes. These refer to the rank. of

melSUf1l: in troup of 100. Thus. wben cn:m mark is on the 85th pen::entile rme of _1lIht for It mIllnS

that only f"rve children ~ 100 of 1he corresponding ... ondsoxbaw_;gltts..- _ _ rocotdod

/nqHct the set of cross iRIdes you have Just 1Mde. If
Iny Ice particularty high or low (for example. ebow the Sl5th pen::entale Or below the 5th percentile). you may want to refer the child to I physiciln. CotnpMe the' most recent set of cross CMC'ks with eartier sets for the same child. If he his chInged npidty In percentile lewis. you may want to cefer him to Jlhysician. Rapid chen;es Ire less likely 10 be significant vmen they occur within
the range from the 25th to the 75th percentile.

09A"'TMENT Of HEAlnt. EOUCATtON. AND WEt..FARE. f"U8LlC HEALTH SERViCE
HEAl..TM RSOURca AC)MINf$TRAnON. NATtONAL CENTER FOft HALTM STATISTtCS. AND CENTE,R FOR OISASE CONTROL

CT - 102

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

BOYS FROM BIRTH TO 36 MONTHS

lb_ 0 40
38 36 34

BOYS FROM BIRTH TO 36 MONTHS

WEIGHT FOR AGE
Age v...onth1:J

6

12

16

H-r-t-- -+~ -I-'- _-+

36

leg.

I ,.
~h-1~

... ~."

32

30

28

26

24

-& 22
~
20

18

16

r--

"

--

12

10 (/ 1/, :- ~ -ri(/1/ - - -'-i--:

- 4-; -7-1-- _ - ;--'-'- 1-" - ~ +-'- - H; J - .' H-r+-j ~t--,- .

__

fl/ , - -+-;- i....,- ;---'-''''-;-

. -: -4-

8 (//~

1---+-0 . ! I-'---~;-' --'--f-+-+--, 1--,--. <--+-

;---,--;- : o----! - ~- : --'-----;-;-- - +-+-

'-----,-
;.__ I--

--...;-.+

,...,.....

~,-

.'" - _.-

....,...-;.- -h-

4

'- -+-f--i............-+- -'--+ ~ I--.J-+-+.+-.

-,---,--,.-,-

.~ --I-'. .-+---

. ..,....+-"~ .--+--i

._''-'','.-__'--.:

-1

--

'

.

.'-

o

12

18

24

36

Aqe Cmonthsl

CT - 103

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22cont'd

BOYS FROM BmTH TO 36 MONTHS

BOYS FROM BIRTH TO 36 MONTHS

in. 0
..~ :...:...~:..::n..+ ~-H--:E~:
40

LENGTH FOR AGE

Age l~l'Ithsl

'0

30

106

.... "", 102

100

:.::::::.~,: :Zf::-!"""L t::: qg

.- oL-A- _._~~ _I-- 9.

,.

Z!~94

:~ ..;6:-'-~~~ ~'. m.. 92

90
sa

.=

86

2.

3:2

___ 70
6_
66

6, 1--
60 58
56 5<
52
oJ

12

18

2'

30

36

Aqe (months)

CT - 104

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

BOYS FROM BmTH TO 36 MONTHS

BOYS FROM BIRTH TO 36 MONTHS
HEAD CIRCUMFERENCE FOR AGE ;n. 36

lb. \<9-
..42 19
40
38 I: 36
19 :l4
i6
32 14
30 \3
28
26 1Z
24 l'
ii.
22 ~, ~
20
18
16
14 &
12 5
10 4
8

20

22

24

so

tit GO

F_32_

26

28

30

32

I

I

70

IlO

LA...."

:l4

36

i I do

38

40 en.

1 '1Ao I

WEIGHT FOR LENGTH

CT - 105

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GROWTH CHART FOR GIRLS: 2 TO 18 YEARS OF AGE

NAME DATE OF BIRTH

GROWTH CHARTS WITH REFERENCE PERCENTILES FOR GIRLS 2 TO 18 YEARS OF AGE
Sutu,.for Aq. Weiqht'for .... W.;;trtfo"St.w,.

_

RECORD.

_

_

These charts to record the growth of the individual child were constructed by the National Center for Health Statistics in collaboration with the Center for Oiseme Control. The charts are based on data from n~ional probability samples representative of girts in the general U.s. popu~n. Their use will direct attention to unusual body sb:e which may be due to diseaa or poor nutrition.
Measuring: TM<.e all measurements with the child in minimal indoor clothing and without shoes. Measure SUture with the child standing. Use beam balance 10 measure weight.
Recording: First take all measurements .nd record them on this front page. Then graph uch measurement On the appropriate chan:. Find the chikr's on the horizontal
scale; theft "follow vertical line from that point to the
horizontal &evel of the chi1d~s measurement (stature or weight). Where the two lines intersect. make a C"Oss marie.
with a pencil. In graphing weight for stature. place the cross
mark directly above the child's stature .-t the horizontal
level of her weight. When the child is measured Ilgain,
join the new set of cross mark.!> to the previous set by nraight lines.

00 not use the weight for stature chart for git'ls who
have begun to develop 'SeCOndary sex characteristics. Interpreting: Many factors influence growth. Therefore,
gfOWt.h dna cannot be used .tone to diagnose disease. but they do allow you to identify some unU$l,RlI chl'dren.
Each chart contains a series of anved tines numbered to show selected percentiles. These refer to the rank of a measure in a group of 100. Thus. when a cross man:. is
on the 95th percentile line of weight for -cae it means
th.t only flYe children among 100 of the corresponding Md sex have weights greater th.n th.rt recorded.
Impt the set of cross marks you Nve just made. If any are particularly high or low (for example. above the
95th percentile Of below the 5th percentile), you may WIInt to refer the child to a physician. ~ the most recent set of cross marks with eartier sets for the same child. If she has ~ rapidly in percentile leYels. you may want to refer her to physician. Rapid changes are less likely to be significant when they occur within the
range from the 25th to the 75th percentile.
In normal teenagers. the age at onset of puberty.varies. Rises occur in percentile levels if pubertY is early. and these levels fall if puberty is late.

DEPARTMENT OF HEALTH. EOUCATtON. ANn WELfARE. PUBLIC HEALTH SERVice HEALTH RESOURCES AQMINtSTRATtON. NATIONAL CENTER FOR HEALTH STATISTICS. ANO CENTER FOR OISEASE CONTROL

CT - 106

GA WIC PROCEDURES MANUAL FY '96

Attaclu;nent CT-22 cont'd

GIRLS FROM 2 TO 18 YEARS

~. ;'
186 100
180
170

GIRLS FROM 2 TO 18 YEARS

WEIGHT FOR AGE

A,C)e Cye.....Q

\(:~.

9 10 11 12 13 14 15 ,(; 17 1

90

7.
150

140

60 130

t
~ 110
100

.__ .. .l

; ..

---~).

.. ~

.;. . ,

. " "---. ~ _.- --; ---"i -_.

" ..~~

00

4'

80

70

CT -107

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GIRLS FROM 2 TO 18 YEARS

GIRLS FROM Z TO 18 YEARS
STATURE FOR AGE

8

10 11 12 13 ,. 15 18 17 18

1"qo1. . . .1

CT - 108

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

PRE-PUBERTAL GIRLS FROM 2 TO 10 YEARS

PRE-PUBERTAL GIRLS FROM 2 TO 10 YEARS

WEIGHT FOR STATURE

J S111't'l.ft ( __

lb.

100

110

1:l()

130

kg.

'00

1I5

IlO 40

as
"

IlO

30

75

3-~

70
65
~
~ 60
55
so
45
40

30
~
~
n
20
.16

'+
"
,0
35 36 37 38 39 40 41 C2 43 44 4S 46 47 48 4. 50 51 52 53 54
Suturt:(in.)

CT - 109

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

GROWTH CHART FOR BOYS: 2 TO 18 YEARS OF AGE

HAME OATEOF81RTH

GROWTH CHARTS WITH REFERENCE PERCENTILES FOR BOYS 2 TO 18 YEARS OF AGE
sueu,.*.
W-';tdfoc'Aqa W - ' l r f t t f o r S e - t u. .

_

ReCORD.

_

_
-

These dlarts to n!cord the growth of the individual child were constructed bV the National Center for Health Statistics in collaboration with the Center for DiseSe Control. The charts are based on data from n.ional probability samples representative of boys in 1he general US. population. Their use win dired attention to unusual body size which may be due to disuse or poor nutrition.
Measuring: Take .11 measurements with the child in minimal indoor dothing and without shoes. Me-.rre Chture with the child standing. Use beam balance to measure weight.
Recording: first take .11 measurements and reccnd them on this front page. Then graph 9Ch measurement on the appropriete chart. Find the childs ege on the horizontat sale; then follow vertical line from that point to the horizontal level of the dlilds measurement (suture or weight'. Whe~e the two lines intersect. mae a cross mart with. pencil. In graphing weight for statute. piece the: cross mark directly above the child's statUte at the horizontal ~l of his weight. When the chikf is measured ~ain, join the new set of cross marks to the previous set by straight tines.

Do not use the weight for sh:ture chart for boys who h.ve begun to de~lopsecondary sex characteristics.
InterpretiAg: Many factors influence growth. Therefore, growth data cannot be used alone to diagnose diseaSe, but they do allow you to identify some unusual children.
Each chan c:orrtllins series of curved lines numbered to show selected percentiles. These refer to the rank of a measure in group of 100. Thus, when a cross mn is on the 95th percentile line of weight for age it means
*that only five children among 100 of the corresponding and sex hwe weights greater tNn that recorded. Int;p:t the set of aoss ft'I.8fb you have just made. If 4Mty are plrticularly high or low (for example, above the 8Sth pen:entile or below the 5th percentile). you may want to refer the child to a physician. CompiIre the most m::ent set of cross mafb w;th earlier 5eU for the same child. If he hu changed flIlpidly in percentile levels, you may want to tefer him to a physician. Rlpid changes are leu likely to be significant when they occur within the
the range from the 25th to the 75th pe::entile. In normaf teenagers. age at onset of puberty varies.. Rises occur in percentile levels if puberty is early, and these levels bll if puberty is late.

DEI"AftTMENT OF MEALTK. EDUCATlON. AND _-FAIlE.. PUBLiC HEALTH SERViCe HALTH RESOURCES ADMINISTRATtON. NAT'ONAL CENTER FOR ~TH STAT1STICS. ANO CENTER FOR otSEASE COHT~

CT - 110

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

BOYS FROM 2 TO 18 YEARS

210 200 190 180 170 160 150 140
:c 130
~ 120 110 100 80 80 70 60 50 40

BOYS FROM 2 TO 18 YEARS WEIGHT FOR AGE

"
.. -~

2O+-,--r--,,--;--I--+-+-"""-+--+-+-"""'-'-+--;--;--/
10 11 12 13 14 15 16 17 18
Age (yun)

CT - III

GA WIC PROCEDURES MANUAL FY '96

Atta(;hment CT-22 ront'd

BOYS FROM 2 TO 18 YEARS

BOYS FROM 2 TO 18 YEARS
STATURE FOR AGE
in.

30 9 10 11 12 13 14 lS 16 17 18 Age (years!
CT - 112

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-22 cont'd

PREPUBERTAL BOYS FROM 2 TO 11 1/2 YEARS

PRE-PUBERTAL SOYS FROM 2 TO 11Y., YEARS
WEIGHT FOR STATURE

lb.

'.

120

115

110

105

100

95

90

85

80

~ 75
~
70

65

80

55

50

45

40

35

30

25
20 +-+--+-+-t--+--+-+--t-i-ii-l-l-t-'-i-+-,-+-+--+--t--+--+--i
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 Stature {in.}

CT - 113

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-23

WEIGHT FOR HEIGHT TABLE FOR DETERMINING WIC ELIGffiILITY*

Height

Underweight (10%+ Below Normal Weight)

Normal Weight (Standard Weight)

Overweight (20%+Above Normal Weight)

57

101

58

103

59

105

60

107

61

110

62

112

63

115

64

118

65

121

66

123

67

126

68

129

69

131

70

134

71

137

72

140

106-118

134

108-120

137

110-123

140

112-126

143

115-129

146

118-132

150

121-135

154

124-138

157

127-141

161

130-144

164

133-147

168

136-150

172

139-153

175

142-156

179

145-159

182

148-162

186

*Table developed using the mean weight in the "medium" frame range and calculating 10% below and 20% above. Allowance for three (3) pounds of clothing provided.

I. For women eighteen (18) years of age and older.

2. Measure height in inches without shoes.

3. Measure weight in pounds.

*Prepared by the Office of Nutrition, Division of Public Health, Georgia Department of Human Resources, January, 1994. Based on the 1983 Metropolitan Life Tables.

CT-114

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-24

'odyArea air
ips ongue acemd feck
kin

PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Nonnal Appearance shin~ fIrm; not easily plucked bright; clear; shiny; no sores at comers of eyelids; membranes healthy pink and moist; no prominent blood vessels
smooth; not chapped or swollen
healthy; red; do not bleed; not swollen deep red; not swollen or smooth
skin color uniform. smooth, pink; healthy appearing; not swollen
no signs ofswelling, rashes, dark or light spots

Signs Suggestive of Nutrient Deficieney(ies)
lack ofnatural shine; dull; dry;. thin; loss of curl; color changes (flag sign); easily plucked
eye membranes pale;
Bitot's spots; red membranes; dryness ofmembranes dull appearance ofcornea (cornmeal xerosis); softening ofcornea (keratomalacia);
redness and fissuring ofeyelid comers
redness or swelling ofmouth or lips (cheilosis);
bilateral cracks, white or pink lesions at comer.:: ofmouth (angular stomatitis) andlor scars
spongy; bleeding; receding

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

scarlet; raw; edematous (glossitis)
purplish color (magenta); smooth; pale; slick; atrophied taste buds (papillae)
diffuse depigmentation;
darkening ofskin over cheeks and under eyes; scaling ofskin around nostrils (nasolabial seborrhea)
swollen (moon) face; front ofneck swollen (thyroid enlargement) swollen cheeks (bilateral parotid enlargement)
dry _ scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis); pinhead-size purplish skin hemorrhages (petechiae); excessive bruising; ~ swollen pigmentation ofareas exposed to sunlight (pellagrous dennatitis); extensive lightness and darkness ofskin (flaky, pressure sores (decubiti)

inadequate niacin, riboflavin,. folacin, iron, and Vitamins B-6 md Jl..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
inadequate Vrtamin A or essential fatty acids inadequate Vitamin C
inadequate Vitamin K inadequate niacin and tryptophan inadequate protein, Vitamin C, and zinc

:Hands

no cavities, no pain, bright face not swollen

may be some missing or erupting abnonnally; gray or black spots (fluorosis); cavities (caries) [signs are to be severe enough to interfere with mastication and/or other health implications]*
thyroid enlargement (front ofneck); parotid enlargement (cheeks become swollen)

inadequate Vitamin D inadequaleVrtaminA
inadequate iodine inadequate protein

CT - 115

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-24 cont'd

BodvArea
Nails
Muscular and ,keletal rystems

Normal Appearance
finn, pink
good muscle tone; some fat under skin; can walk or ron without pain

Signs Suggestive of Nutrient DeficiencvQes)
nails are spoon-shaped (koilonychia); brittle, ridged nails,. pale nail beds
muscles have "wasted" appearance; baby's skull bones are thin and soft (craniotabes); round swelling of front and side ofhead (frontal and parietal bossing); swelling ofends ofbones (epiphyseal enlargement); small bumps on both sides ofchest wall (on ribs)beading ofribs; baby's soft spot on head does not harden at proper time (persistently open anterior fontanelle); knock-knees or bow-legs; bleeding into muscle (musculo-ske1etal hemorrhages); person cannot get up or walk properly

Nutrient Considerationfs)
inadequate iron VItamin A toxity
inadequate protein inadequate thiamin U1adequale Vitantin D

~As stated under nutritional risk criterion "I". Clinical Manifestations ofMaInutrition, Dental Problems, Lead Poisoning."
A.dapted from American Journal of Public Health. Supplement, November 1973, p. 19. and 1992 Georgia Dietetic Association Diet ManuaL

CT - 116

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-25

RECOMMENDED DAILY SERVINGS CHART

Food Group Milk, Yogurt & Cheese
Meat, Poultry, Dry Be=, Eggs, Nw Group Fruit Group

Birthto5f6 Month<;
Breastmilk, every 2-3 hrs or Iron fortified fonnula, 2.:5 ozllb (18-350zs) None
None

5/6 Mouths to 1 y"",
Breas1miIk,every 2-4 brs or Iron fortified formula, 2.5oz/lb (24-350zs)
Add.&< 6 months and before 9 months
Add.&< 6 months and before 9 months

Vegetable Group None

Add.&< 6 months and before 9 months

Brea.d, Cereal, Rice & Pasta Group

Non'

Add ironfortified cereal at 5-6 months

NOll'

None

1 PortIoadzelsftduced.by:apprn:;lal3tely VJrd,ueeptformilk 1P.reg:aaataadbre:utreeding1eal:lgenlleed-4Sfl't1tDg$
3W_:z4yc:u'S2AdWNkIleedJ~
"R:omme:a.ded.servtugsslzes:
Milk. Yogurt & C1Ieese Group:
1 serving =

1 cup miIkIyogurt 1-* OlD1ce5 natural cheese (LC cheddar, colby, longhorn) 2 01lllttS processed cheese (Le. american. swiss) IM~ cup ice cream 2 cups cottage cheese
Meat. Poultry, Dry Beans. Eggs. Nuts Group:
Other foods from this group count as 1 ounce oflean meat 1 serving =

1 egg 'hcupnuts 7t cup cooked dry beans 2 tablespoons peanut butter

1-3 Yearollf'

4-6Yearolcf

2=vmgs
(16 ounces total)

2=vmgs (16 ounces
total)

3 ounces

:s ounces

PreglWrt Teen! Pregnant Adult" 3-4=vmgs'
6 ounces

2 servings 1 serving = 3Tcookedl pie<:es Ihfruit lh.cjuice
3 servings 1 serving = 3T cooked or chopped 0/3 craw
leafY
6 servings
1 serving =
V: slice or
v.. ccooked
Ihcdry =1
As needed to meet

2 servings 3 servings
RDA fa r energy

3 servings 9serving:s

Fruit Group: 1 serring=
1 medimn fruit 6 ounces joice %. cu.p pieces
Vegetable Group: 1 serving-
~ cnp cooked or chopped 1 cup raw leafy
Bread. CereaL Rice & Pasta Group: 1 sen'ing-
1 slice 7t cup cooked cereal, rice or pasta Y.i cup dry cereal

BFTeen/BF Adult 3-4=vmgs'
6oun= 3=vmgs
4 servings
11 servings

Teen PP/ Adult PP'
2 servings 3 servings 6 servings

CT - 117

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-26

INAPPROPRIATE FOOD PRACTICES Inappropriate Food Practices for Women. Infants. and Children: 1. Use of nutritional supplement(s) in excess of 100% of the R.D.A's other than those prescribed
by physician. (I) 2. Any practice of pica. (I) Additional Inappropriate Food Practices for Prenatal Women:
4, 1. Intake of more than 300 mg of caffeine per day. (I, 5, 6, 7)
2. Intake of alcohol. (4, 9) 3. Intake ofless than 8 cups of clear liquids per 24 hours. (I) Additional Inappropriate Food Practices for Infants: 1. Use of an infanrfeeder. (I, 10) 2. Routinely drinking from bottle while lying down. (1) 3. Liquids and/or food in the bottle except for formula, breast milk or water. (1, 10) 4. Inappropriate formula preparation. (I) 5. Introduction of solids prior to 5 months of age. (I, 2) 6. Food consistently used as a pacifier or reward for the infant. (1) 7. Introduction of mixed food groups prior to the introduction of the ingredients singly. (2, 10) 8. Unflavored water not offered daily, once diet intake includes anything other than
breastmilklinfant formula. (1) Additional Inappropriate Food Practices for Children: 1. Food consistently used as a pacifier or reward. (1) 2. Unflavored water not offered daily. (1) 3. Drinking from the bottle after one (1) year of age, unless medically indicated. (7)

CT -118

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-26 cont'd

4. Inappropriate formula preparation (if formula prescribed). (1)

References for Inappropriate Food Practices

(I) Office of Nutrition, Division of Public Health, Georgia Department of Human Resources: Nutrition Guidelines for Practice. 1986.

(2) Committee on Nutrition: Pediatric Nutrition Handbook. American Academy of Pediatrics,
~Q2~
(3) American Dietetic Association: Meal Time! Happy Time! A Guide for Parents. Chicago, Illinois.

(4) National Academy of Sciences, Institute of Medicine: Nutrition During Pregnancy. Washington, D.C., 1990

(5) Berger, Alvin: Effects of Caffeine Consumption on Pregnancy Outcome. Journal of Reproduction Medicine, 33 (12):945-956, 1988.

(6) Martin, T.R., Bracken, M.B.: The Association Between Low Birth Weight and Caffeine Consumption During Pregnancy. American Journal of Epidemiology 126:813-821, 1987.

(7) Watkinson, B., Fried, PA: Maternal Caffeine Use Before, During and After Pregnancy and Effects Upon Offspring. Neurohehavioral Toxicology and Teratology 7:9-17,1985.

(8) Georgia Dietetic Association, Inc., Diet Manual

Edition,

(9) U.S.DA, U.S.D.H.H.S., Home and Garden Bulletin No. 232, 1985 and H. & G. #232, 1-7; 1986.

CT - 119

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-27

GEORGIA SUBSIDIZED CHILD CARE PROGRAMS

AFDC PEACH/JOBS

Provides child care benefits to AFDC clients enrolled in approved education, employment or training activities; and those services and activities which provide Job Opportunities and Basic Skills (JOBS). These activities include:

Adult EducationlGED preparation/High school Job readiness training Job search Vocational skills training Jobs Corps Job development Work experience On-the-job training Work supplementation Employment Post secondary education (24 month limit)

TCC (Transitional Child Care)

This is an entitlement program which provides benefits to former AFDC recipients. Recipients must be employed to receive benefits under this program.

Title IV-A At-Risk

Child care benefits are made to non-AFDC recipients who are low income working parent(s).

CCD Block Grant

Benefit recipients must be low income working clients and can not be a recipient of AFDC grant.

Food Stamp Employment and Training (E & T)

Provides benefits to participants in approved PEACHIFood Stamp employment and/or training activity residing in an E & T county.

Foster Child Care

Benefit recipients are children in foster care.

*The above are non-payment benefit child care programs.

CT 120

GA WIC PROCEDURES MANUAL FY '96
GEORGIA WIC PROGRAM REFERRAL FORM

Attachment CT-28

Georgia WIC Program Referral Form
Name: Address: Date: Height: Weight: Any nutritionally related medical conditions? Ifyes,specify:
IAfyneysc,slipneiccaiflym: anifestations of malnutrition? ~'__

USDA policy does not pennit discrimination bocause of race, color, national origin, sex, age or handicap. Any person m.o believes he or she bas been discriminated against in'Bhy"USDA related activity should write immediately to the Secretary of Agriculture. Washington., D.C. 20250.
Date ofBirth:

Dale: Hematocrit: Hemoglobin:

Yes

No

_

Yes

_No

Any dentBl problems severe enough to interfere with mastication? Ifyes, specify:

Yes

No

_

Any evidence oflead poisoning?

Yes

No

Ifyes, specify: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

WOMEN ONLY

EDCIDelivery Date:

Blood Pressure:

Number ofPrevious

Pregnancies "

_

Pregravid Weight

INFANTS ONLY

Breastfeeding:

Yes

Birthweight:

Weeks Gestation:

HEALTH PROFESSIONAL

Signaturelfitle Agency Address

Live Births No

Breastfeeding: Date Taken:

Yes

No

Miscarriages, Abortions

Birthlength:

_

Agency Telephone

_

_

CT -121

GA WIC PROCEDURES MANUAL FY '96 NUTRITIONAL RISK PRIORITY SYSTEM

Attachment CT-29

1. Priority 1: 2. Priority 2:
3. Priority 3: 4. Priority 4: 5. Priority 5:

Pregnant women, breastfeeding women and infants with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.
Breastfeeding women who do not qualifY under Priority 1, but are breastfeeding Priority 2 infants.
Infants up to six (6) months of age born to women who were Program participants during their pregnancy.
Infants up to six (6) months of age born to women who were not Program participants during pregnancy but had a nutritional need.
Children with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.
Postpartum teenagers who are not breastfeeding.
Pregnant women, breastfeeding women and infants with a nutritional need because of poor diet 9ri119m~1lIi!_iiWY.~
Children with a nutritional need because of poor diet Ptl,!;\ml!!lj~~!11Pi!~gf,l~l~

6. Priority 6:

women with a nutritional need,

CT -122

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-30

GEORGIA DEPARTMENT OF HUMAN RESOURCES STATE WIC PROGRAM
NON-PARTICIPATIONffECHNICAL ASSISTANCE REPORT FFY'96

DATE OF CONSULTATION: (by phone or site visit)

STATE STAFF:

DATE REPORT DUE TO STATE:

DISTRICT:

DISTRICT STAFF:

DISTRICT REPORT DATE:

1. Reason for low non-participation rate:

2. Which clinics are involved:

3. Plan of action taken:

4. Is Technical Assistance requested? Yes_ No_

Report submitted by:

_

CT - 123

GA WIC PROCEDURES MANUAL FY '96

Attachment CT-30 cont'd

STATE WIC OFFICE State Report

Non-Participation Rate!Technical Assistance Summary Report

District_ _

Unit_ Coordinator's Name:

_

Date call was made to District:

_

Date report (from the District) is due: (20 days)

_

Actual date report received:

_

Non-Participation rate based on phone call:

_

Non-Participation Rate 80 days from the phone call:
I s a Technical Assistance visit needed? No__

_

yes

_

If yes, when is the date for the visit?

_

The visit will cover: .

District/Clinic,

_

District/Clinic,

_

District/Clinic

_

District/Clinic

_

District/Clinic'--

_

CT - 124

TABLE OF CONTENTS

II. Nondiscrimination Clause

..

RO-l

III. Public Notification.

.......... RO-2

IV. Civil Rights

A. "---And Justice for All"

...........

. . RO-3

B. Training. .

. . RO-3

C. RaciallEthnic Identification . . .

. . RO-3

D. Collection of Racial Ethnic Data

.. RO-3

E. Discrimination Complaints ....

. RO-4

Written and Verbal Complaints

.. RO-4

V. Fair Hearing Procedures - Participants

. RO-5

A. Hearing Official

.........

. . . . . . . .. . .... RO-6

B. Request(s) for Hearing

.. RO-6

C. Claimant's WlC Program Record Summary Form

.. RO-7

D. Case Record Disclosure Prior to the Hearing

. RO-7

E. Adjusting Complaints

. .. RO-8

F. Continuation of Benefits . . . . . . . . . .

.

RO-8

G. Denial or Dismissal of a Request for a Hearing

RO-8

H. Notification of the Hearing

RO-9

I. Conduct of the Hearing and the Claimant's Rights

RO-g

J. Attendance at the Hearing

RO-IO

K. The Hearing Record

...........................

RO-IO

L. Thellearing Decision.

. RO-ll

M. Notification of the Hearing Decision. .

. .. RO-ll

N. Appeal Rights ofthe Claimant. . . . . . . .

. .. RO-ll

O. Implementation of Fair Hearing Decision

. RO-12

P. State Rules of Procedure .

. . RO-12

VI. Fair Hearing Procedures - Migrants. . . . .

...........

. .. RO-12

VII. VIII.

Administrative Appeals - Local Agency Availability of Hearing Records

Attachments:

RO-I

Rights and Obligations Handout

_

RO-2 Claimant's WIC Program Record Summary

.

RO-12 RO-13
..... RO-14 . .... RO-16

GA WIC PROCEDURES MANUAL FY '96 L RIGHTS AND OBLIGATIONS OFWIC APPLICANTSfPARTICIPANTS WIC applicants/participants are entitled to certain rights including, but not limited to, protection against discrimination and the right to a fair hearing when benefits are denied. WIC applicants/participants are obligated to provide true infonnation and follow program requirements.
In addition to the rights and obligations stated on the handout, the applicant! participant also has the right not to be charged for any WIC service. Local agencies may use their administrative funds to reimburse health departments for WIC services provided to applicants/participants.
IL NONDISCRIMINATION CLAUSE All State agencies are required to implement a public notification program to infonn participants and applicants, particularly minorities, of their rights and responsibilities, their protection against discrimination, and the procedures for filing a complaint. Therefore, any materials that provide information about WIC Program benefits and eligibility, regardless of the intent, design, or source, must contain the nondiscrimination statement. These RO-l

GA WIC PROCEDURES MANUAL FY '96
materials include brochures, posters, visuals, and any other literature produced by vendors, formula companie~ or other interested parties. Examples of materials which require the nondiscrimination statement include:
1. Notices of warning or adverse action to applicants/participants, local agencies, vendors, and employees or employment applicants. This includes items such as notices of ineligibility or disqualification, fair hearing procedures, and cards or letters for missed appointments.
2. All outreach and referral materials.
3. Participant identification cards (ID), food instrument folders, or food lists for participants and vendors that describe the WIC Program's participation requirements and benefits.
4. Letters of invitation to participate in the public hearing process which are sent to organizations and other interested parties, and media announcements of the public hearing.
5. Newsletters that convey WIC benefits and participation requirements.
The current nondiscrimination statement is:
"This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250".
III. PUBLIC NOTIFICATION
A. When WIC Program Coordinators give interviews to the local media, the nondiscrimination statement should be included in verbal statements and on written documents. Any public or media discussions ofWIC by local Program staff should be documented for review by State agency monitoring staff. The Office of Public Affairs for the Georgia Department of Human Resources prepares a news release annually to publicize the availability of WIC benefits. The news release is distributed to newspapers statewide.
B. WIC Program regulations and guidelines must be made available to the public on request. These documents include the WIC Federal Register Georgia WIC Program State Plan, and Georgia WIC Program Procedures Manual. Income Guidelines are part ofthe Procedures Manual and must be given to the public if requested.
C. The section, Special Populations (SP), outlines procedures for insuring program
RO-2

GA WIC PROCEDURES MANUAL FY '96
participation by non-English speaking populations.
D. Handicapped persons must be treated equally with all other eligible applicants/participants. WIC Program services must be accessible without hardship to disabled applicants and participants.
IV. CIVIL RIGHTS
A. "--And Justice for All"
The "--And Justice for All" poster must be displayed in a conspicuous location in each WIC clinic site. The poster is available in English and Spanish and may be ordered from the State WIC Office.
B. Training
Civil rights training must be provided for all staff who have contact with WIC applicants/participants. This training must be provided for all new employees, as well as annually (federal fiscal year) for all current employees. A list of participants and an agenda for each training must be documented and kept on file for three (3) years plus the current year.
C. Racial/Ethnic Identification
Each applicant/participant must be identified by race or ethnic group. In order to do this, local agency staff should:
1. Request the applicant to make a self- identification. When self-identification is made, the interviewer should make it clear to the applicant that the information is for statistical use only and that no other use will be made of the information.
2. Make the determination if necessary.
3. Accept race information that is provided by the applicant. WIC staff must not dispute an applicant/participant's statement of his/her race.
D. Collection ofRacial/Ethnic Data
Collection and reporting ofracial and ethnic participation data is a requirement of Title VI of Civil Rights Act of 1964. The "Ethnic Participation Summary Report" provides information on client participation by ethnic status and priority. The report records data by local clinic and summarizes the data by DistrictlUnit and State. This report should be reviewed and maintained in DistrictlUnit files. Data must be maintained under safeguard which will restrict access to authorized personnel and maintained for
RO - 3

GA WIC PROCEDURES MANUAL FY '96

three (3) years. Participants records must not be coded nor filed by racial/ethnic origin. The .Georgia WIC Program must not allow any coding system on the outside of Medical Records, tickler cards, appointment or any related WIC document which can openly distinguish applicants/participants by race, color, national origin, sex, or handicapped.

E. Discrimination Complaints

All discrimination complaints, written or verbal, must be filed within one hundred and eighty (180) days ofthe alleged discriminatory action. No applicant/participant should be discouraged from filing a complaint directly with the Secretary of Agriculture or the Director ofthe Office ofEqual Opportunity if he/she feels discrimination has occurred.

I. Written Complaints

Persons seeking to file discrimination complaints may file them either with the Secretary ofAgriculture, Washington, D.C. 20250. A copy if available, should be sent to the State WIC Office. All complaints must be received by the Civil Rights Division of the Department of Agriculture no later than ten (10) days from the initial receipt of the complaint. The State WIC Office will send a copy of the discrimination complaint to the USDA Regional Office.

The complaints should include the name of the agency and/or individual towards which the complaint is directed, and include a description of the alleged violation. Anonymous complaints shall be handled like any other complaint.

2. Verbal Complaints

In the event a complainant makes verbal allegations and refuses, or is not inclined, to place such allegations in writing, the person to whom the allegations are made shall write up the elements ofthe complaint for the complainant. Every effort shall be made to have the complainant provide the following information:

a. Name, address and telephone number of the complainant.

b. The specific location and name of the local agency, and person delivering

WlC services.

.

c. The nature of the incident or action that led the complainant to feel discrimination was a factor, or an example of the method of administration which is alleged to have a discriminatory effect on the public or applicant/participant.

d. The basis on which the complainant feels discrimination exists (e.g. race,

RO-4

GA WIC PROCEDURES MANUAL FY '96
color, national origin, sex, age, or handicap).
e. The names, titles, and addresses of persons who may have knowledge of the discriminatory action.
f. The date(s) during which the alleged discriminatory action occurred, or if continuing, the duration of such actions.
All discrimination complaints, written or verbal, must be filed within one hundred and eighty (180) days ofthe alleged discriminatory action. No applicant/participant should be discouraged from filing a complaint directly with the Secretary of Agriculture, Washington, D.C. 20250 if he/she feels discrimination has occurred.
All complaints written and verbal must be maintained on file at the clinic site where complaint originated.
v. FAIR HEARING PROCEDURES - PARTICIPANTS
WIC Federal regulations require the State agency to establish a hearing procedure under which a person or hislher guardian will be guaranteed the right to appeal a decision or action by the State or .local agency which results in the individual's denial of participation, suspension, or termination from the Program. The participant must be informed in writing of hislher right to a fair hearing and of the method by which a hearing may be requested. Due to an increase in the number of Fair Hearings request and budget constraints, the following procedures have been developed in order to (1) Reduce the number of Fair Hearings and (2) Improve our current procedures.
In order to insure that the above occurs, the following procedures must be discussed with each new applicant/participant at certification:
1. Limited funding of program 2. The Priority System 3. Waiting List 4. Reasons for the denial of benefits or termination from the program.
Focusing efforts at the time of application should prove to be valuable in ensuring a more informed public, thus reducing the number ofFair Hearings. Also, at the time of fair hearing request, theWlC Coordinator will need to conduct a preliminary conference with the applicant. This conference may resolve the issues, particularly when the individual may misunderstand a program policy or not be aware that certain procedures are required by regulations. The State Agency must also conduct a preliminary conference with the applicant/participant prior to the actual hearing. In the event a Fair Hearing is still requested, the State Agency will try when possible to hold group hearing procedures on the same day. As a group the applicant could receive information on fair hearing procedures,
RO- 5

GA WIC PROCEDURES MANUAL FY '96
including their rights and responsibilities concerning the hearing process, the role of the hearing officer, the.!ime frame for fina1 decisions and any other pertinent information. Cases can then be heard on an individual basis with the specifics of each case being separately discussed.
In the event a participant request a fair hearing, all benefits remain in force until a decision has been rendered.
The following is the Georgia WIC Fair Hearing Procedure:
A Hearing Official
The Fair Hearings Unit of the Department of Human Resources is responsible for action on each fair hearing request. The Hearing Officer of the Fair Hearings Unit, an impartial party, is vested with full authority in the conduct of the hearing process. This includes the conduct of hearings, keeping all files and records, and furnishing information for proper reports. The Hearing Officer is fully responsible for conducting hearings properly and promptly in accordance with the rules and regulations established by the State. The Hearing Officer shall have the authority to do the following:
1. Administer oaths or affirmations;
2. Insure that all relevant issues are considered;
3. Request, receive, and make a part of the hearing record all evidence determined necessary to decide the issues being raised;
4. Regulate the conduct in the course of the hearing consistent with due process to insure an orderly hearing;
5. Order, ifrelevant and necessary, an independent medical assessment from a source mutually satisfactory to the claimant and the State agency; and
6. Render a hearing decision based exclusively on the hearing record and matters officially noticed.
B. Request(s) for Hearing
A request for a hearing is defined as any clear expression by the individual or the individual's parent, guardian, caretaker, or other representative, that an opportunity to present his case to a higher authority is desired. The State and local agency shall not limit or interfere with the individual's freedom to request a hearing.
The hearing request must be filed within sixty (60) days from the date the local agency
RO-6

GA WIC PROCEDURES MANUAL FY '96
mails or gives the applicant or participant the notice of adverse action to deny, suspend, or tePDinate benefits. Fair hearing requests shall be submitted to the Fair Hearings Unit, 47 TriOi"ty Avenue, Room 542-H, Atlanta, Georgia 30334.
A hearing request shall be effective upon receipt of a verbal or written request. A verbal request received within the sixty (60) day time limit by the local agency shall be accepted as timely filed. The forty-five (45) day period allowed for rendering a hearing decision shall begin on the day the fair hearing request is received by the local agency.
Upon request, the local agency shall assist the claimant in submitting a request for a fair hearing. The claimant shall be advised by the local agency of any legal services available that can provide representation at the hearing.
C. Claimant's WIC Program Record Summary Form
The local agency shall prepare the Claimant's WIC Program Record Summary Form (Attachment RO-2). Within three (3) working days the completed form and written request shall be submitted to the Fair Hearings Unit, 47 Trinity Avenue, Room 542-H, Atlanta, GA 30334. A copy of the form shall be sent to the State WIC Office. If the hearing request is filed initially with the State agency, a copy will be immediately forwarded to the local agency.
The local agency has the responsibility of maintaining contact with the claimant and must report promptly to the Hearing Officer any change in circumstances, including changes in mailing address. As soon as the local agency receives notification that a hearing has been scheduled, the local agency WIC Program Coordinator shall immediately review the record to:
1. Re-examine the action of the local agency and the circumstances ofthe claimant to determine if an adjustment can be made.
2. Review claimant eligibility on all points other than the point at issue. All hearing requests, whether timely or not, must be submitted to the Fair Hearings Unit. The local agency will secure any additional evidence necessary for the hearing.
D. Case Record Disclosure Prior to the Hearing
All documents and records to be used in the hearing will be available for examination by the claimant anPJor his/her designated representative prior to and during the fair hearing. Such examination shall be made at the local agency. "Designated representative" is understood to mean an attorney, friend, or personal counselor of the claimant. Upon request, the local agency shall make available, without charge, the specific materials necessary for a claimant or his representative to determine whether a hearing should be requested or to prepare for a hearing. The claimant and/or his
RO-7

GA WIC PROCEDURES MANUAL FY '96
representative will be given an opportunity to copy any materials in the file which are
relevant to t:ht<.appeal. Confidential material which cannot be released to the claimant
or hislher representative shall be removed from the file prior to such copying and will not be used at the hearing. When local agency reproduction equipment and supplies are available, the agency staff will operate the equipment. When reproduction equipment is not available, long hand notes may be made by the claimant or his/her representative.
E. Adjusting Complaints
The local agency has the responsibility of taking proper action in adjusting all complaints. If an applicant/participant is dissatisfied, the local agency shall review his/her status with him/her. If the claimant so desires, the local agency shall assist him/her in filing the hearing request and preparing for the hearing. If the local agency and the claimant arrive at a mutually satisfactory decision prior to the hearing, the claimant may withdraw his/her request for the hearing in accordance with the withdrawal procedures. The local agency may amend or reverse its decision at any time prior to a hearing, regardless of the claimant's decision on withdrawal. In the case of withdrawal, amendment, or reversal, the local agency shall notifY the Hearing Officer immediately, attaching a copy of the withdrawal or new notification and a summary supporting the corrective action taken by the local agency. If time does not pennit written notification, the Fair Hearings Unit shall be notified verbally with immediate follow-up in writing.
F. Continuation Of Benefits
Participants who appeal the tennination of benefits within fifteen (I5) days from date of notification shall continue to receive Program benefits until the
Hearing Officer reaches a decision. Applicants who are denied benefits at initial certification or at subsequent certifications may appeal the denial, but shall not receive benefits while awaiting the hearing.
The local agency shall promptly inform the individual, in writing, if participation status changed," pending the hearing decision.
G. Denial or Dismissal of a Request for a Hearing
The Fair Hearings Unit of the Department of Human Resources shall not deny or dismiss a request for hearing unless:
1. The request for hearing is not received within the sixty (60) day time limit.
2. The request is withdrawn in writing by the appellant or a representative.
RO- 8

GA WIC PROCEDURES MANUAL FY '96
3. The appellant or representative fails, without good cause, to appear at the scheduling hearing.
4. The appellant has been denied participation by a previous hearing and cannot provide evidence that circumstances relevant to Program eligibility have changed in such a way as to justify a hearing.
H. Notification of the Hearing
The hearing shall be conducted within three (3) weeks from the date the State received the hearing request. A time and place shall be arranged in order for the hearing to be accessible to the participant/designated representative. At least ten (10) days prior to the hearing, the Fair Hearings Unit shall provide written notice to all parties involved to permit adequate preparation of the case. The notice shall contain the following:
I. A statement of the time, place, and nature of the hearing.
2. A statement ofthe legal authority and jurisdiction under which the hearing is to be held.
3. A reference to the statutes and regulations involved.
4. A short and plain statement of the matters asserted. Ifthe agency or other party is unable to state the matters in detail at the time, the notice may be limited to a statement of the issues involved.
5. A statement that the State will dismiss the hearing request ifthe individual or his representative fails to appear at the hearing without good cause.
6. A statement that the participant/designated representative may examine the case file prior to the hearing.
The Hearing Officer may change the time and place of the hearing upon his own motion or that by the claimant. The Hearing Officer may adjourn, postpone, or reopen the hearing upon receipt of additional information at any time prior to mailing the hearing decision. Should the Hearing Officer exercise the option of rescheduling the hearing, the claimant shall be given at least ten (10) days advance notice of such action.
1. Conduct of the Hearing and the Claimant's Rights
If, at the hearing, it becomes evident that the issue involved is different from the one on which the hearing was requested, the Hearing Officer shall exercise discretion and may conduct the hearing on the newly emerged issue. In such instances, the hearing
RO-9

GA WIC PROCEDURES MANUAL FY '96
may be continued so all concerned may prepare additional evidence.
The claimantJaesignated representative shall be provided with an opportunity to:
1. Bring witnesses;
2. Advance arguments without undue interference;
3. Question or refute any testimony or evidence, including an opportunity to confront and cross-examine adverse witnesses;
4. Submit evidence to establish all pertinent facts and circumstances in the case.
The local agency shall have the same opportunities listed above.
J. Attendance at the Hearing
The hearing shall be attended by a representative of the agency which initiated the action being contested and may be attended by the individual and/or his representative. Other local agency staff may attend and participate in the hearing process at the discretion of the Hearing Officer. The hearing may also be attended by friends and relatives of the claimant if the claimant so chooses.
K. The Hearing Record
The Hearing Officer sha1I compile an official hearing, i.e., an entirely new record which covers all points of eligibility dealing with the issues directly related to the action being appealed. The record shall include:
1. All pleadings, motions, and intermediate rulings.
2. A summary of the oral testimony plus all other evidence received or considered, except that oral proceedings, any part thereof, shall be transcribed or recorded upon request. Upon written request, a transcript or tape of such oral proceedings, or any part thereof, shall be furnished to any party to the proceedings.
3. A statement of matters officially noted.
4. Questions of matters officially noted.
5. The decision by the Hearing Officer.
6. All staffmemoranda and dates submitted to the Hearing Officer in connection with
RO-IO

GA WIC PROCEDURES MANUAL FY '96
the case.
L. The Hearing Decision
Decisions of the hearing authority shall comply with Federal law, regulations, and policy and shall be based on the hearing record. The hearing decision shall take into consideration only those issues directly related to the action being appealed and shall be based exclusively on evidence and other material introduced at the hearing. A decision by the Hearing Officer shall be binding on the local agency and shall summarize the facts of the case, specify the reasons for the decision, and identify the supporting evidence and the pertinent regulations or policy. The decision shall become a part ofthe record.
M. Notification of the Hearing Decision
Within forty-five (45) days of the receipt of the request for a hearing the claimant and!or representative shall be notified in writing of the decision. If the decision is in favor ofthe claimant and participation was denied or discontinued, benefits shall begin immediately. If the decision is in favor of the agency, as soon as administratively feasible, any continued benefits shall be terminated as decided by the Hearing Officer and efforts will be made to collect the claims. In addition, the decision will inform the claimant of any right to appeal known to the Hearing Officer and shall advise that an appeal request may result in a reversal of the decision.
N. Appeal Rights of the Claimant
When a decision is adverse to the claimant, he/she has the right to appeal to a Hearing Officer for Final Appeals. The claimant shall be allowed fifteen (15) days to request review ofthe decision by the Hearing Officer for Final Appeals. The Hearing Officer for Final Appeals shall have all the powers and delegated authority of the Commissioner to make a decision. He/she may take additional testimony or remand the case to the Hearing Officer for such purpose. The decision will be based upon the record from the original hearing as augmented before the Hearing Officer for Final Appeals and shall either affirm, reverse, or modify the original decision to assure full compliance with Federal iaw, regulations, and policy.
Ifthe claimant requests review ofthe Hearing Officer's decision, the usual standard of promptness is automatically waived. The claimant and his legal representative shall be notified, in writing, of the decision of the Hearing Officer for Final Appeals and of his/her right to judicial review. If the claimant is dissatisfied with the decision of the Hearing Officer for Final Appeals, he/she has the right to pursue judicial review (e.g., civil court).
RO-ll

GA WIC PROCEDURES MANUAL FY '96
o. Implementation ofFair Hearing Decision
With1nfive (5)working days from the receipt of the hearing decision, the local agency must notifY the Fair Hearings Unit, in writing, that the decision has been received and acted upon. Upon receipt ofthis notification, the appeal file will be closed unless a final appeal is made.
P. State Rules of Procedure
The State agency shall provide and distribute upon request, to any interested party, that portion of the Georgia WIC Program Procedures Manual which outlines the Fair Hearing Procedures.
VI. FAIR HEARING PROCEDURES - MIGRANTS
Because migrant farmworkers and their families may leave a Program area after a very short time, it is important that fair hearing procedures for migrants be expedited. The Fair Hearings Unit has been notified by the State WIC Office that they should act as quickly as possible when a fair hearing is requested by a migrant applicant/participant. When a local agency receives a fair hearing request from a migrant, they should attempt to find out how long the migrant will be in the Program area and should convey this information to the Fair Hearings Unit and State WIC Office.
VII. ADMINISTRATIVE APPEALS - LOCAL AGENCY
Local agencies and or potential agency may appeal a State agency decision when application to participate in the WIC Program is denied or terminated, or when a decision is made which adversely affects the local agency's participation in the program, such as a reduction in food or administrative funds.
The local agency must request a hearing from the State agency within thirty (30) days after the action which is being appealed was taken. The hearing must be scheduled no later than thirty (30) days after the request for hearing is received by the State agency with the local agency being given fifteen (15) days advance notice of the time and place of the hearing. The proposedadverse action must be postponed from the time a hearing is requested until a decision is reached. Upon request, the local agency may reschedule a hearing date one (1) time. Sixty (60) days advance notice must be provided to a local agency before disqualification from Program participation.
The local agency will have ample opportunity to present its case at the hearing, including the opportunity to confront and cross examine adverse witnesses. The local agency may be represented by counsel, if desired, The local agency may review the case file prior to the hearing.
RO-12

GA WIC PROCEDURES MANUAL FY '96 In the event of a hearing, an administrative hearing panel will be appointed by the Director ofthe Maternal & Child Health Branch to hear local agency appeals. This panel will consist of one (1) local aiency WIC Program Coordinator and two (2) representatives from the Division ofPublic Health. This panel will be an impartial decision maker with no personal interest or involvement in the outcome of the hearing or the statutory and regulatory provisions governing the Program. The basis of the decision shall be stated in writing, though it need not amount to a full opinion or contain formal findings of fact and conclusions oflaw The local agency will be notified of the decision within sixty (60) days from the date of the request. If a State decision is rendered against the local agency, the local agency may pursue judicial review of the decision.
VITI. AVAILABILITY OF HEARING RECORDS The State and local agencies shall make all hearing records and decisions available for public inspection and copying; however, the names and addresses of the participants and other members of the public must be kept confidential.
RO-13

GA WIC PROCEDURES MANUAL FY '96

Attachment RO-1

Georgia Department of Human Resources Division of Public Health/Georgia WIC Program

RIGHTS AND OBLIGATIONS

1. The rules for signing up and taking part in the WIC Program are the same for everyone regardless of race, color, national origin, age, handicap or sex.

2. You may appeal any decision made by the clinic about your eligibility for WIC by asking for a fair hearing.

3. The clinic will give you information about food that is good for you. Health service referrals are also available to you. The clinic would like for you to use these services.

4. Information on your WIC form will be used to review the program and to tell us how many people are on WIC.

5. All information about you being on WIC is private.

6. The food you get from WIC is only for you or your children.

7. You may be taken off WIC if:

* You do not tell the truth.
* You get vouchers from more than one (1) WIC program at the same time.

* You do not keep your certification appointments. (Rescheduling WIC appointments
may take from 7 to 20 days depending on the clinic schedule).

* You do not get your vouchers for two (2) months in a row. * You sell your vouchers for money.

* You trade your vouchers for anything.
* You use your vouchers to buy food that is not on the list.

* You use abusive language with clinic staff, store clerks or managers.

* You are physically violent with clinic staff, other WIC clients, or store
personnel.

* You sell your WIC food.
8. Ifyou do not keep your appointments, the number of vouchers issued to you or your child will

RO-14

GA WIC PROCEDURES MANUAL FY '96 be reduced.

Attachment RO-l cont'd

SCHEDULE FOR PICKING UP VOUCHERS LATE

"Failure to keep appointments will reduce the number of vouchers you receive.

~,.

~.. ,,_w. T ~._

Less than 7 davs late 7-13 days late

14-20 days late

21-31 days late

LATE PICK-UP
Women & Children full package
3 vouchers issued (3/4 package)
2 vouchers issued (1/2 oackage)
1 voucher issued
(Tlii n.rhop)

I

Infants

I

full oackage

full package

1 voucher issued 0/2) oackage
1 voucher issued
(TI? n.,.,Jr.op)

Ifyou have any questions about this form, you may askfor help or call the clinic.

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agricul.ture, Washington, D.C. 20250.
Form 3768 (Rev.) NOTE: SEE LATE PICK-UP SCHEDULE ADDENDUM (ATTACHMENT 19) FD-60
RO -15

GA WIC PROCEDURES MANUAL FY '96

Attachment RO-2

GEORGIA DEPARTMENT OF HUMAN RESOURCES CLAIMANT'S WIC PROGRAM RECORD SUMMARY

SECTION I - IDENTIFICATION

DistrictfUnit.

_

WIC ID#

_

ApplicantIParticipant:

_

Claimant (if different from above):

_

Address:

Street Number and Name

City Phone Number:

State _

Representative:

_

Zip Code

ApplicantIParticipant Race/Sex: (Circle item #) L white male 2. white female 3. nonwhite male

4. nonwhite female

County:

_ Date ofRequest:

_

Date ofAppointment:

_

Date ofNotification:

_

FOR STATE OFFICE USE ONLY:

Request number:

_

Date request filed:

_

RO -16

GA WIC PROCEDURES MANUAL FY '96 SECTION IT - 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 under five (5) years of age

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)'

_

Attachment RO-2 cont'd
Date Date Date Date Date Date Date Date Date

B. Agency Inaction (Circle item number): 1. Failure oflocal agency to meet proc~~sing standards: (specify)

2. Other: (specify)

RO -17

GA WIC PROCEDURES MANUAL FY '96

Attachment RO-2 cont'd

SECTION ill - 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 (specilY briefly):

B. WIC regulations applied by local agency:

C. Participant's income eligibility information:

Signature/Title ofWIC Personnel

Signature ofWIC Coordinator

Prepare in triplicate Original - Fair Hearings Unit File Copy - State WIC Office File Copy - District/Local Agency

Program Name

Address

City

State

Zip Code

Telephone Number

RO -18

TABLE OF CONTENTS

SECTION ONE - FINANCIAL MANAGEMENT

1. Agreement with State Agency

AD-I

II. Financial Procedures

-.. AD-I

A. Budgeting B. Computerized Accounting System

..........

. .. AD-I . .. AD-~

C. Monthly Income and Expenditure Report . . . . . . . . . . . . .

. .. AD-3

III. Administrative Cost Categories . . . . . . .

_

_. .

. .. AD-4

A. General Administration

.

. .. AD-4

B. Nutrition Education Costs
Ii:

D. Client Services

_

AD-5

_

AD-~

E. Indirect Costs

'

AD-8

IV. Shared Costs

AD-~

A. Shared Operational Costs ......................................... AD-~

B. Shared Equipment

.

C. Shared Personnel Costs

AD-\tW

V. Time Studies

AD-ll

A. Introduction

AD-ll

B. Time Study Participants
C. Prior Approval D. SummarySheet(~

AD-12 AD-i~ AD-m~

E. Analysis

AD-14

F. Time Study Results

AD-14

G. Record Retention. . . . . . . . . . . . . . . . . .

.

ADJ

VI_ Definitions ofWIC Time Study Activities .. _

......... .

AD-15

A. Administrative

..........

B. Client Services. . . . . . . . . . . . . . . . .

. _. AD-15

.

-.AD-i~ii

C. Nutritional Education .. _. . . . . . . . . . . . . . . . . . . . .

.

AD-17

D. Breastfeeding E. Either Administrative or Nutritional Education F. Other VII. Purchasing Procedures A. Equipment (Excluding Medical Equipment) B. Medical Equipment. . . . . . . . . . . . C. ADP Equipment Purchases $5,000-$25,000 D. ADP Equipment Purchases $25,000-$200,000 E. Supplies F. Central Supply Forms

_1 ~;,

i ~;Bla.1

~1

VIII. Allocation of Funds

A. Food Funds

B. Administrative Funds

IX Food Cost Projection Report

X. Program Income

SECTION lWO - PROGRAM ADMINISTRATION 1. Retention of Records
A. Definition of Records B. Records and Reports - Accessibility of Records C. Retention Schedule

Page
ADti AD-il,
AD~t! AD-19 AD-19 AD-20 AD-22 -. ~ .AD~I AD-g~ AD-g~
AD~ AD-:I:
AD-I:
AD-::'1 AD-~~
AD-;'~
AD-gog AD-;iog
AD-~~

II. WIC Acronym and Logo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A Authority......................................

.

Page . .. AD-~~
AD~~g

B. Official Use

AD-,?i

C. Special Use

......................................... AD~~i

D. Unauthorized Use .... ......................................... AD~~~

Lobbying Restrictions

..

AD-,~4

Attachments: AD-I Sample Formulas .... AD-2 Index of Functional Activity Codes AD-3 WIC Time Study Data Collection Fonn "

"". ". ". ""

................ AD~W@

""

"AD-,~7

" . " "AD-,~ll\

AD-4 AD-5

WICfFamily Planning Time Study Data Collection Form " " . " " ".. " ... " " .... " "ADi:!

Time Study Summary

". ". ".

."

" " . " . " " . " " .. AD-4'~

AD-6 Information"Needed for USDA Approval of Non-Major ADP Equipment" " . " " .. " " . " "

" " " " . " .. " AD-Jti

AD-8 AD-9

Contract Budget "."""""" Monthly Expenditure Report

""

".. """."

" .. " .. "." AD-47

". "". "".. """"

" " " . " " " " "AD-48

AD-ll AD-12

Nutrition Materials Available in Central Supply " . " " " .

Equipment Inventory Form " " "

"". "". ". ".

.." .. "."".""." .AD-5l ."" ....... "." .AD-52

1<-

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

GA WIC PROCEDURES MANUAL FY '96

SECTION ONE - FINANCIAL MANAGEMENT

I. AGREEMENT WITH STATE AGENCY

Prior to October 1 of each year, all local agencies operating a WIC program, excluding contracted local agencies, must sign the Memorandum of Understanding (Attachment AD-7). Two (2) copies ofthe agreement must be signed by the District Health Officer and returned to the State WIC Office. The State Health Director in turn signs both agreements, and one (1) copy of the agreement will be returned to the local agency and the other copy will be maintained on file at the State WIC Office.

II.

FINANCIAL PROCEDURES

A Budgeting

Private, non-profit agencies contract with the State WIC Office to provide services to WIC participants. A copy ofthe Contract Budget form is included in this section as Attachment AD-8.

All other local agency budgets should be prepared using current Department
of Human Resources budget instructions. See the Grant-in-Aid Policy and
Procedures Manual Part m, E., Attachment 1.

Current instructions may be obtained from the District Administrator or the Public Health Grant-in-Aid Office. Budget forms may be ordered from Central Supply (Form#'s 5410,5411, and 5412).

Local Agency financial staff must have accessibility to all state and federal manuals which relate to the operation and management ofWIC funds:

Georgia WIC Procedures Manual USDA FNS Instruction 808-1 OMB Circular A-87 and A-I02 Grant-in-Aid Policy & Procedure Manual Parts m.E, Attachment 1 and IXA,B. 7 CFR3016

B. Computerized Accounting System

Local agencies using a computerized accounting system must perform a daily back-up of the hard drive to floppy diskettes. All diskettes must be

AD-I

GA WIC PROCEDURES MANUAL FY '96
maintained in the financial office and secured.
Hard copies of all computerized financial documents relating to WIC administration must be retained in the local agency financial office. Supporting documents pertinent to WIC administration must also be retained and available for reference and review. Examples of such records are: employee travel statements, invoices, contracts, etc. The retention of these records (floppy diskettes and hard copies) must be maintained in accordance with WIC regulations.
The following areas are especially important in formulating WIC budgets and are in accordance with the Public Health Grant-in-Aid instructions:
I. Nutrition education costs should be determined locally and separated from administrative costs for the income and expenditure reports. A minimum of one-sixth (116) of administrative funds should be budgeted and reported as nutrition education.
2. WIC administrative allocations are made at the beginning of each State Fiscal Year. Increases and/or decreases may occur during the year based upon availability offunds. Any across-the-board increases which will be added to the annual administrative allocation will be identified as such. Any conversion funds allocated will be identified as rebate funds and will not be added to the annual administrative grants.
3. The current Merit System Pay Scale is to be used for computing salaries.
4. For part-time employees, indicate percentage ofWIC time used in computing salaries.
5. Check to make sure that each position is listed numerically, in Merit System position number order, using all seven digits assigned. This must be done, without exception, in order for reconciliation to be made with the Personnel Expense Reimbursement System (PERS) data.
6. Check to be sure that all anticipated position (or incumbent) changes are clearly designated, using separate lines and amounts with explanations. When adding or reallocating positions effective early in
AD-2

GA WIC PROCEDURES MANUAL FY '96

the budget year, make sure that the yellow copy of Requests for Personnel Action is attached to the budget. If a later effective date is budgeted, send the yellow copy of Request for Personnel Action to the Grants Office, allowing sufficient lead time for processing.

7. Pensions and benefits are computed on regular salaries as follows:

a. FICA

@ 7.65% (on first $49,500)

b. Retirement @ 17.89% (for employees under the "old"

retirement plan, subtract

$84/yr or $7/mo.)

c. Health

Insurance @ 10.70%

If the county is projecting cost for Unemployment Insurance (Contributory), this expense should also be budgeted in this section.

C. Monthly Income and Expenditure Report

The Monthly Income and Expenditure Report (Form #5110) must be completed and submitted to the Financial Services Grant-in-Aid Accounting Office, 47 Trinity Avenue S.W., Room 301-H, Atlanta, Georgia 30334, no later than the eighth (8th) day of the month following the reporting month. A copy must be sent to the State WIC Office. For instructions on completing the fonn, see the Grant-in-Aid Policy and Procedures Manual Part III, E.

If corrections are made to a report after a copy has been submitted to the State WIC Office, notify the State WIC Office of the changes. If the notification is by phone, it must be followed by written documentation. This is very important in order for the State WIC Office to balance with Financial Services Grant-in-Aid.

The Expenditure Report for private non-profit agency contracts (Attachment AD-9) is completed in a similar manner. These are sent monthly to the State WIC Office for payment.

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GA WIC PROCEDURES MANUAL FY '96 ID. ADMINISTRATIVE COST CATEGORIES

A. General Administration

In general, allowable administrative and operational costs are those costs necessary to fulfill program objectives and are lOO percent supported by WIC funds. These include both direct and indirect costs. Specific allowable costs are:

1. All cost generally considered to be overhead or management costs. 2. Costs associated with program monitoring, prevention of fraud,
general oversight and food instrument accountability and reconciliation. 3. General management clerical support, the cost of payroll and personnel systems, accounting and bookkeeping, audits and other financial services and legal services. 4. WIC administrative salarieslbenefits necessary to conduct outreach services, monitoring and payment, vendor monitoring, to keep administrative records and to prepare and maintain fiscal and program management reports. 5. Training in administrative and AI>P areas and audit tracking. 6. Fair hearing costs. 7. Liability Insurance*. 8. The cost of batching and mailing Moter - Voter Registration applications as well as costs associated with maintaining a file of Moter-Voter declinations.

*

Liability Insurance - The Official Code of Georgia Section 45-9-4(a)

is the authority for the purchase or provision of liability insurance to

protect "officers, officials or employees" against personaIliability for

damages arising out ofthe performance oftheir duties.

No authority exists for the purchase or provision of liability protection for individuals that are not employees, officers or officials. The liability insurance and Merit System Assessments for local agency positions are charged to the State Grant-In-Aid line item, not to the districts.

Interest expense of any kind, including purchases, is not an allowable WIC cost.

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GA WIC PROCEDURES MANUAL FY '96
The following costs are allowable only with prior approyal from the State WIC Office and U.S.DA:
1. Capital expenditures with a unit value in excess of $5000. 2. Management studies performed by consultants or outside agencies. 3. Rental of space or maintenance, in lieu of rental in a publicly owned
building. 4. Rearrangements and alterations to facilities. 5. Insurance and indemnification. 6. Indirect costs.
Note: *The following are allowable ADP costs that do not require prior approval.
1. ADP service treated as indirect costs and included in a cost allocation plan approved by DHR.
2. Software and minor components intended for the maintenance of existing systems.
3. Commercially available software packages.
B. Nutrition Education Costs
A local agency is required to spend a minimum of one-sixth (116) of its administrative funds on nutrition education. As long as there is sufficient and appropriate documentation, the following are allowable nutrition education costs:
1. Cost for salaries of employees who plan and/or perform nutrition. education, including any related travel costs.
2. Individual or group education sessions with participants, including the time necessary to plan, prepare for, and conduct the sessions
3. Training ofpersons providing nutrition education, including any travel expenses and teaching aids.
4. Evaluation of nutrition education, including the collection of participant views.
5. Mailing of nutrition education materials.
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GA WIC PROCEDURES MANUAL FY '96
6. Nutrition education materials, including the cost to develop, print, and distribute these materials. A contract for the development and production ofmaterials is allowable, as long as the provisions of Ol\1B Circulars 7-CRF 3016 and A-87 are met.
7. Purchasing equipment necessary to conduct nutrition education activities.
8. Monitoring of nutrition education, including travel time, as well as time necessary to evaluate these activities.
9. Developing Nutrition Education Plans.
10. Translators for materials and interpreters.
11. Purchasing foods for demonstrations and for sampling by WIC participants, as part ofthe agency's nutrition education program. The State and local agencies must maintain records which support food purchases made for nutrition education purposes.
Only activities directed toward helping participants understand the importance of nutrition in relation to health are allowed as nutrition education costs. A dietary assessment, completed as part of the certification procedure, is not an allowable nutrition education cost. A dietary assessment completed for the purpose of nutrition counseling, however, may be counted as a nutrition education expenditure.
In order to document nutrition education costs, a time study must be completed by WIC personnel who engage in both nutrition education and other administrative activities.
C. Breastfeeding Costs
A local agency is required to spend WIC breastfeeding funds for breastfeeding related costs and activities. As long as there is sufficient and appropriate documentation, the following breastfeeding costs are allowable:
1. Salaries of employees who plan and/or perform breastfeeding promotion and support activities.
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GA WIC PROCEDURES MANUAL FY '96
3. Individual or group sessions with participants, for the promotion and support of breastfeeding. This includes the time necessary to plan, prepare for, and conduct the sessions.
4. Training ofpersons conducting breastfeeding promotion and support activities.
5. Evaluation and monitoring ofbreastfeeding promotion and support activities, including participant surveys.
6. Development/procurement and distribution of materials, instructional curricula, etc., related to breastfeeding promotion and support.
7. Development and updating of the biennial Breastfeeding Promotion and Support Plan.
8. Interpreters, and translators for materials. 9. Travel and related expenses incurred by WIC staff; related to any of
the above items. 10. Costs ofreimbursable agreements with other organizations, public or
private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.
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GA WIC PROCEDURES MANUAL FY '96

11. Prorated costs of clinic space devoted to educational and training activities related to breastfeeding, including space and furniture set aside for nursing during clinic hours.

D. Client Services

In general, allowable client service costs are all costs expended to deliver food and other client services and benefits. Specific allowable costs are:

1. WIC staffsalarieslbenefits, medical supplies and equipment necessary

to conduct diet and health assessments required in the certification

process.

2. Salary/benefits ofWIC staffwho issue food instruments and explain

their use.

-,

3. Cost necessary to refer client to other health care and social services,

to coordinate services with other programs.

4. Activities which promote a broader range ofhealth and social services

for participants.

5. Costs to conduct and participate in surveys/studies which evaluate the

impact ofWIC on its participants.

6. Certification costs, including laboratory fees and other costs for time

spent on certification.

7. Transportation ofrural participants to clinics, when prior approval has

been given by the State agency.

8. Translation of materials and use ofinterpreters.

9. Costs for administrating the food delivery system.

E. Indirect Costs

Any local agency charging an indirect cost must have an Indirect Cost Plan which has been approved by State WIC Office, and the Department ofHuman Resources. Such a plan must incorporate all local agency programs. Indirect costs can only be charged to the WIC Program if they are also charged to other programs. Services received by the WIC Program for indirect cost expenditures are:
a. Budgeting!Accounting b. Personnel and Payroll c. Automated Data Processing (ADP) d. Space Usage/Maintenance e. Communication/Phone/Mail Service

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GA WIC PROCEDURES MANUAL FY '96

f.

Central Supply

g. Legal Services

h. Procurement and Contracting

1.

Printing and Publication

j.

Audit Services

k. Equipment Usage/Maintenance

1.

Other

IV.

SHARED COSTS

A. Shared Operational Costs

All operating expenses charged to and paid by WIC must be documented. All expenses must have source documentation such as invoices, contracts, etc. Those expenses which WIC shares with another program must be documented and shown as an actual expense or an equivalent prorated charge. Listed below are examples of an allowable basis for allocating costs shared by two (2) or more programs.

Cost a. Duplicating b. Janitorial Services c. Maintenance d. Printing e. Telephone
(1) Long Distance
f. Utilities

Basis of Allocation
Per Copy, Based on Log Square Footage
Square Footage Per Job
Number ofExtensions (pay share or basic charge per month)
Log and Pay Actual Costs Square Footage

For example, charges for janitorial services must be based on WIC square footage, divided by total square footage, times the total janitorial service cost for the space. Documents outlining shared cost procedures must be on file for all operational costs charged to WIC.

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GA WIC PROCEDURES MANUAL FY '96
B. Shared Equipment
The cost of equipment used by WIC and another program may be charged to WIC if it is prorated on an equitable basis. The agency may claim the appropriate share of the equipment cost as a direct WIC Program cost. This applies to medical equipment, nutrition education materials, and any other shared administrative expense. As stated in OMB Circular A-87, a cost is allowable to a program to the extent ofbenefits received by that program.
C. Shared Personnel Costs
WIC payrolls must be supported by a time study. Employees' salaries and fringe benefits that are expensed, in part, to WIC and in part to other programs must be supported by appropriate distribution of tin1e~ Source documentation must be kept on file to support the reimbursement method, (i.e. rate for service, full-time equivalents, or breakdown of administrative client services and nutrition education time).
In addition, documentation must be updated at least every year and when significant changes in salaries or procedures occur.
USDA and the State agency will pursue a recovery ofProgram funds when source documentation is not available to support charges paid with Program funds. Estimates are never an acceptable means for documenting Program charges.
Several acceptable methods for documenting shared personnel costs are:
1. Rates
A rate may be used for standardized tasks which are performed frequently. Rates are based on the average of salaries and fringe benefits of employees who perform a specific task.
The rate, once determined, is related to a time factor. The time factor must be based on time studies in which the actual tasks are observed and documented. Either the person(s) performing the task or another responsible individual may observe and record the time required and compute an average time. All time factors must be verified by a time study.
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GA WIC PROCEDURES MANUAL FY '96

In cases where the task is completed in more than one way within a local program area, separate rates (and separate time studies) must be calculated.

Local rate documentation must be available for audit and review. Documentation includes the time study data collection forms, applicable computation of average salaries, and the dates when rates were established.

2. Daily Time Logs

Daily time logs should be kept for shared personnel who have a broad

range of duties which vary from day to day. Logs should be dated and

signed by the staff member.

-~

3. Time Studies (see Section V)
v. TIME STUDIES

DoClimentation of Costs

The Georgia WIC Program will continue with this approved time study methodology until the Division ofPublic Health allocation methodology has been approved/or when the DHHS Cost Allocation Unit has prescribed an alternative methodology.

All personnel costs paid by WIC must be supported by a time study. The time study will enable each local agency to document time spent by non-WIC paid employees for providing WIC services. It also will enable each local agency to document the time spent on nutrition education, breastfeeding, administrative or client service activities (see Definitioils Section VI). All time study methodologies (data collection form, definition of codes, who will participate in the study, dates of the study, etc.) must have approval from the State WIC Office prior to implementation. Approval must be requested at least sixty (60) days prior to the scheduled implementation date. Upon completion, a copy ofthe documentation and analysis of the time study must be sent to the State WIC Office.

A. Introduction

Time studies used to substantiate salary costs expensed to the WIC Program must be valid and reliable and the results must be correctly applied. This has been an objective in the Georgia WIC State Plan since Fiscal Year 1984 in an

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GA WIC PROCEDURES MANUAL FY '96
effort to standardize WIC time studies in Georgia.
The time study will:
(a) Document personnel costs shared by WIC and other programs.
(b) Document federal regulation compliance of required nutrition education expenditures.
(c) Document federal regulation compliance of required breastfeeding expenditures (contracted employees and local agency employees).
(d) Document general administration and client service expenditures.
Federal regulations require the State agency to expend at least one-sixth of its administrative grant for nutrition education and the Food and Nutrition Service (FNS) designated amount for breastfeeding activities. The State, in turn, requires local agencies to spend at least one-sixth ofits administrative grant for nutrition education and designated amount for breastfeeding. The State agency must document the total amount ofadministrative expenditures attributable to nutrition education and breastfeeding in its final closeout report for each fiscal year. Ifthe State Agency's reported nutrition education and breastfeeding expenditures are less than the amount required to be spent, FNS will issue a claim for the difference and accordingly reduce the State agency's Letter of Credit and grant level for that fiscal year.
Local agencies must complete a time study every year to document staff time spent performing WIC duties. This year's most current time study data, along with salary information, will be used by local agencies to compute WIC costs. This information must be reported to the State agency.
B. Time Study Participants
The following staff are required to participate in the time study:
1. Non-WIC paid personnel if local agencies are using the time study to justify reimbursement ofpersonnel costs.
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GA WIC PROCEDURES MANUAL FY '96
2. All staff whose salaries are paid in part or in full by WIC or whose time is used to offset shared costs.
C. Prior Approval
Review and approval oftime studies will be handled on an on-going basis at the State level. Each local agency must receive approval of the time study methodology from the State Agency prior to data collection. A written request for approval must be made at least sixty (60) days prior to the date the local agency plans to begin data collection. In order for the State agency to properly review, evaluate, and approve a time study, the local agency must submit the following, in writing:
1. AnalysislUse. Each local agency must submit a plan of how the time study will be analyzed and used. This plan includes formulas, what the data and the formulas will be used for, and the summary sheets to be used (See Attachment AD-I for examples offormulas).
2. Instructions. Each local agency must submit the detailed instructions that will be used by local agency staff who are participating in the study (see Attachment AD-2 for Index of Functional Activity Codes).
3. Data collection form. Each local agency must submit a copy of the actual time study data collection form for prior approval. The form must contain spaces for the employee's name, signature, and date(s) on which the data will be collected. Two forms have been developed by the State agency, from which districts may choose to use. Attachment AD-3 is a form to capture only WIC Program data. Attachment AD-4 is a form to capture both WIC and Family Planning data.
Time must be recorded in increments of fifteen (15) minutes. Each box on the data collection form must be coded according to the activity in which staff were involved at the end of the time increment. Each box on the data collection form must be coded with only one (I) activity code. Arrows
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GA WIC PROCEDURES MANUAL FY '96
cannot be used to document continuous activity. Since the activity perfonned at the end of the time increment must be documented, it may not always be the activity which involved the most time during the 15 minute interval.
In the event that a FLSA exempt employee works more than 8 hours in one day (compensatory time) the activities should be coded on the day and time when compensatory time will be
taken. For example, if an employee works nine (9) hours in
a day, thefirst eight (8) hours are recorded on that day. The activitiespeifonned in the ninth hour will be recorded on the day the compensatory time is taken.
4. Definitions. Definitions must be submitted for the activities or activity codes listed on your data collection fonn.
5. Minimum Time Sample: Time studies must be conducted for a minimum offour (4) consecutive weeks. Each local agency must submit the dates on which the time study data will be collected.
D. Summary Sheet(s)
A summary sheet listing each individual who participated in the time study must be submitted to the State WIC Office within sixty (60) days of the completion of the study. All individual data collection forms that support this summary sheet must be retained on file at the District Office. Attachment 5 is an example of a summary sheet. Districts may choose to develop their own summary sheet. However, approval will be required as outlined under III.
E. Analysis
All calculations used in compi.li.ng the analysis must be submitted to the State WIC Office. The fonnulas used for these calculations must have already been approved (refer to III.). Local Agencies will receive written approval of these calculations within thirty (30) days of submission to the State WIC Office.
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GA WIC PROCEDURES MANUAL FY '96
F. Time Study Results
Documentation of the final time study results must be submitted by September 30th of the year in which it was completed to allow time for approval. Any local agency which does not have an approved time study by September 30th may have funds withheld until such time as the required time study data is provided to the State WIC Office. The results of time study are valid for one federal fiscal year. Therefore, the time study must be completed yearly. The calculations for reimbursement purposes must be used from the analysis of one time study until the analysis ofthe next. Local Agencies will be monitored on the most recent time study. State staff will verifY the correct application of the pre-approved formulas and the final calculations while conducting your on-site review. At the time ofyoii{program review, if a time study has not been conducted and compk'r(' a:; outlined in this policy, the local agency will be given ninety (90) calendar days to complete a time study. For local agencies unable to meet this 90 day timeframe, a waiver may be granted. However; the results ofthe completed time study will be applied retroactively.
G. Record Retention
All time study documentation (i.e., time sheets, summary sheets, etc.) must be retained for three (3) years plus the current Federal Fiscal Year.
VI. DEFINITIONS OF WIC TIME STUDY ACTIVITIES
WIC activities must be defined as Administrative, Client Services, Nutrition Education and Breastfeeding. They may include, but are not limited to, following:
A. Administrative:
1. WIC Program management duties such as, computer system management/maintenance, time study activities, grant writing, preparation and maintenance of program management reports, overseeing food instrument accountability and reconciliation, and legal services.
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GA WIC PROCEDURES MANUAL FY '96
2. WIC Program fiscal management duties such as, budgeting, monitoring and reviewing expenditures, bookkeeping, payroll, preparation and maintenance of fiscal and program management reports, audits and other financial services.
3. WIC general administration duties such as, monitoring and reviewing administrative operations, office management, record keeping of personnel actions and maintaining leave records, clerical support duties.
4. All vendor management activities (vendor monitoring, payment processing applications, training, prevention offraud).
5. All duties perfonned to conduct outreach activities designed to encourage and/or increase participation in the WIC Program.
6. Any other duties which cannot be classified as Nutrition Education or Client Services.
. 7. Batching and mailing Moter-Voter Registration Applications as well
me as maintaining a of Moter-Voter declinations.
B. Client Services:
1. All assessments or parts of assessments made in order to determine eligibility, e.g. income screening, anthropometric assessment, nutrition risk assessment, diet recall (for the purpose of determining eligibility), etc.
2. All assessments or parts of assessments made during the infant's mid certification nutrition assessment appointment, e.g. anthropometric assessment, nutrition risk assessment, and diet recall.
3. All paperwork related to the certification/subsequent certification/midcertification assessment, e.g. fi1ling out the turnaround document and WIC Assessment/Certification Forms, completing the Notice of TerminationlIneligibilityiWaiting List Form.
4. Termination ofa participant from the Program at any time other than during a certification/subsequent certification appointment. Examples: ifa participant does not pick up vouchers for two (2) months in a row; program abuse; participant moving out of your District; missing a subsequent certification appointment.
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GA WIC PROCEDURES MANUAL FY '96

5. Time spent issuing vouchers, educating the participant on how to use vouchers and when and where to pick them up again, making their next appointment, preparing vouchers from ADP Contractor, voiding vouchers, time spent tracking down a medical record necessary to issue vouchers, issuing ID cards, filling out tickler cards, and other related areas.

6. WIC follow-up which includes medical/health assessments made at times other than certification, subsequent certification, or midcertification assessment. Examples: hematocrit or height/weight follow-up referral follow-up, follow-up on missed appointments, etc.

7. Receiving and resolving participant/vendor complaints.

8. Participation in completing surveys and studies which evaluate the impact ofWIC on its participants.

9. Coordination of services with other programs.

10. Participation in activities which promote a broader range of health and social services for participants.

11. Referrals made to other health and human service programs.

12. All costs expended to deliver food and other client services and benefits.

13. Time spent asSISting clients with Moter-Voter registrations and declinations.

C. Nutrition Education:

1.

All activities necessary to conduct and document the provision of

nutrition education to participants (individuals or groups) during

certification, subsequent certification, or mid-certification assessment.

These activities include set-up time and documentation in the medical

record.

2.

Secondary nutrition education contacts.

3.

Dietary assessments done at any time other than to detennine

eligibility for the Program. Example: taking a dietary recall in the

third month of certification for the purpose of counseling an obese

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GA WIC PROCEDURES MANUAL FY '96

child.

4.

Writing and updating the biennial nutrition education plan.

5.

Planning for classes.

6.

Researchingldevelopinglpurchasingldistribution of nutrition

education materials.

7.

Grant writing for nutrition education activities. Writing a grant for the

purpose of getting a computer to schedule appointments would be

classified as an administrative duty, not nutrition education.

8.

Monitoring nutrition education activities.

9.

Translating nutrition education materials.

10.

Interpreters' time providing nutrition education.

11.

Other duties directly related to and supporting nutrition education

(i.e., staff development/nutrition education workshops).

D. Breastfeeding:

1. All activities necessary to conduct and document the promotion and support of breastfeeding among participants. This includes salaries and benefits for WlC staff, non-WlC professionals and peer counselors.

2. Writing and updating the biennial breastfeeding promotion and support plan.
3. Planning for classes.

4. Researching, developing, translating, purchasing and distributing breastfeeding promotion and support materials.

5. Grant writing for breastfeeding promotion and support activities.

6. Monitoring and evaluating breastfeeding promotion and support activities.

7. Interpreters' time providing breastfeeding information.

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GA WIC PROCEDURES MANUAL FY '96

8. Participating in State and local planning committees dedicated to breastfeeding promotion and support.

9. Other duties directly related to breastfeeding promotion and support, i.e., staff development, breastfeeding workshops.

E. Either Administrative or Nutrition Education:

Activities such as telephone time, travel time, staffmeetings, and training must be included in the category they support. Prorating may be appropriate for these specific activities, between the categories they support.

NOTE:

(I)Time spent performing nutrition education activities may be classified as "Administrative" but time spent performing administrative activities may not be classified as "Nutrition Education." However, the State agency recommends that all nutrition education activities be classified as "Nutrition Education" and all administrative activities be classified as "Administrative. "

F. Other:

(2)Administrative and Nutrition Education activities completed in a fee paid program (e.g., EPSDT, Family Planning) cannot be charged to WIC.

Annual leave, sick leave, lunches, breaks and other approved leave (i.e., military, jury duty, etc.) need not be included in either ofthese categories.

VTI. PURCHASING PROCEDURES

A Equipment (Excluding Medical Equipment)

All equipment purchased solely with WIC fuuds must be used for WIC purposes only. Equipment cost and use may be shared with other programs, however documentation must be available for review.

All equipment purchases must be made in accord with CFR Part 3016 and State purchasing policies, all of which should be on file at the local agency. Requests to USDA for approval ofnon-major ADP equipment should include the information contained in Attachment 6.

As a general rule, all items costing over S100.00, or having a life expectancy of three (3) years or more are considered equipment. However, there are

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GA WIC PROCEDURES MANUAL FY '96

some items which do not meet these requirements and are considered equipment.

1. Approval of Purchases

Allowable office equipment (excluding ADP equipment) may only be

purchased if funds are available in the local agency's current budget.

No approval from the State WIC Office is necessary unless the cost

exceeds $5000 or costs are shared with another program. Equipment

purchases exceeding $5000 require prior approval from the State WIC

office and USDA. Local agencies should list intended equipment

purchases on the Budget Expense and Resource Summary, Form

#5410, which is submitted to Public Health Grant-in-Aid and copied

to the State WIC Office.

-:

Approval ofthis budget constitutes approval of equipment until the approved budget has been received. If a requested equipment purchase is disapproved, the Public Health Grant-in-Aid Office will refer questionable purchases to the State WIC Office for investigation.

2. Reporting Purchases

Equipment purchases are reported in the "Current Expenditures" section ofthe Monthly Income and Expenditure Report, Form #5110, on the following lines:

a. EQUIPMENT $1000 or MORE PER ITEM:

All equipment purchased whose unit cost exceeds or equals $1000.00 should be reported.

b. EQUIPMENT UNDER $1000 PER ITEM

All equipment costing under $1000 per item should be reported here. Ifyou purchase two files at the same time, at a cost of$525.00 per file, they would be recorded.

B. Medical Equipment

Before purchasing medical equipment, local agencies should analyze their needs to determine what type of equipment is appropriate for use at that particular clinic. For example, a hematofluorometer would be appropriate when a local agency is participating in a lead screening program, but would

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GA WIC PROCEDURES MANUAL FY '96
not be appropriate for routine screening for anemia
Local agencies should not send requests for medical equipment to the State WIC Office ifthere are appropriated monies in their budget for the purchase ofthe needed medical equipment, the cost of the medical equipmeni does not exceed the maximum ($5000), and ifthe equipment will be used only for WIC Assessments/Certifications.
1. Approval of Purchases
a. Guidelines
According to Section 246.14(d) (2) of WIC Program regulations, local agencies may use adrninistr.i:tive grant monies to purchase medical equipment used to screen applicants for the WIC Program. For all medical equipment allowed by WIC regulations, local agencies are delegated the responsibility for approving purchases, using the following guidelines:
(I) Only medical equipment specifically listed in the WIC regulations, Section 246.12(b) (3) (iii), may be approved fur purchase. The list of equipment includes only centrifuges, spectrophotometers (includes hemoglobinometers), measuring boards, skin fold calipers, scales, and hematofluormeters used for determining eligibility of applicants/participants.
(2) The cost ofthe medical equipment shall not exceed the $5000 limit established by FNS in accordance with Office of Management and Budget Circular A-87 for capital expenditures. While this amount is the maximum allowed, equipment can often be obtained for substantially less than the maximum. If the cost of anyone (I) piece of equipment exceeds the $5000 maximum, the equipment must have prior approval by the State WIC Office and USDA prior to purchase.
b. Required Information
The following information, at a minimum, should be provided to the State WIC Office for our transmittal to FNS when an approval to purchase is submitted:
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GA WIC PROCEDURES MANUAL FY '96
(a) A description of the equipment to be purchased, including the name ofthe manufacturer and the price. The price should be itemized sufficiently to identify the cost of attachments (if priced separately), transportation charges, discounts, taxes, etc.
(b) List the price of each bid. A minimum of three (3) bids must be obtained. If the lowest bid was not selected, please include justification for favoring a higher bid. If the equipment was purchased under a pre-negotiated State contract, please indicate this in the request.
(c) Include a statement certifying that the equipment will be used exclusively for WIC Program purposes. Ifthe item of equipment is to be shared, describe how the cost will be prorated between users.
(d) Include a statement that procurement was made in accordance with the provisions of? CFR Part 3016, "Uniform Federal Assistance Regulations", and State and/or local procurement procedures.
2. Reporting Purchases
Medical equipment purchases are reported on the Monthly Expenditure Report, Form #5110, in the manner described in the preceding section.
C. ADP Equipment Purchases $5000 - $25,000
Prior approval from the State WIC Office and USDA must be obtained for all ADP equipment purchases above $5,000 per unit but less than $25,000 in aggregate. Software purchases in this range do not require approval.
EXCEPTION: Equipment with a unit cost below $5,000 does not require prior approval unless it is part of a project whose total cost exceeds $25,000.
1. Approval of Purchases
The request for approval should be submitted at least 15 days prior to the anticipated purchase date. The request should be in the form of
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GA WIC PROCEDURES MANUAL FY '96
a letter and be submitted under the signature of the State WIC Director. The request must include the following:
(a) A statement that the requested equipment is not a part of a larger ADP project.
(b) A brief description of the need for the equipment and justification of the proposed purchase.
(c) A statement that the equipment will be used for WIC only or a cost allocation proposal.
(d) A list of equipment to be purchased, associated cost and the agency where the equipment will be located. - ~
Larger ADP projects cannot be divided up to avoid the more complex approval requirements of higher threshold levels.
D. ADP Equipment Purchases $25,000 - $200,000
Prior approval from the State WIC Office and USDA must be obtained before a State agency expends more than $25,000 but less than $200,000 for any ADP hardware, software, or services. For projects with anticipated costs above $200,000, please refer to FNS Handbook 901.
1. Approval ofPurchases
The request for approval should be submitted at least 30 days prior to the anticipated purchase date. The request should be in the form of a letter and be submitted under the signature of the State WIC Director. The request must include the following:
(a) A statement that the requested equipment is not a part of a larger ADP Project.
(b) A description ofthe need for the equipment, software and/or service including:
(1) an explanation of current operations and why they do not meet the needs;
(2) an explanation of how the proposed acquisition will meet needs.
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GA WIC PROCEDURES MANUAL FY '96

(c) A statement that the requested expenditure will benefit WIC only OR a cost allocation proposal.

(d) A list of equipment and software to be purchased, associated costs, and the agency where it will be located.

(e) A description ofthe service to be provided and the anticipated cost.
E. Supplies

Supplies are expendable items used in the course ofWIC Program activities,

and are obtained using the local agency's purchasing procedures. Purchases

must be made in accordance with State purchasing regulations and sufficient

documentation must be maintained for each purchase.

-,

Funds for supplies must be budgeted and submitted to Grant-in-Aid on the Budget Expense and Resource Summary Form, Form #5410 and (copied to the State WIC Office). However, no approval of supply purchases is necessary, either from Grant-in-Aid or from the State WIC Office.
Refer to the Georgia WC User Manual for information regarding the
ordering of supplies for the ADP System.

F. Central Supply Forms

All Central Supply requests for WIC and Office of Nutrition forms must be ordered by the District through the State WIC Office and the Office of Nutrition. All orders must be correctly completed and separated from orders for other programs, e.g. Immunization, Women's Health, Child Health (see Attachments AD-IO and AD-II) All requisitions must be sent to the State WIC Office or the Office ofNutrition for approval before the orders will be filled. DO NOT SEND ORDERS DIRECTLY TO CENTRAL SUPPLY. Requests will not be approved by telephone.

AD-24

GA WIC PROCEDURES MANUAL FY '96
Prior approval is !lQ1 required for a local WIC Program to rent space to house Program operations in a publicly or privately owned building. The following
information must be sent to the State wic Office for all rentals.
1. Justification as to why the space is needed 2. Number of square feet to be rented 3. Rate per square foot per year 4. Total monthly rental 5. Total annual rental 6. Address of the building in which space is to be rented 7. Name and address oflessor 8. Whether the building is publicly or privately owned 9. What the rental rate includes (e.g. utilities and maintenance) 10. Date rental payments will start 11. Statement that the space to be rented will be used for WIC Program
purposes only 12. Statement that rental rate to be paid is comparable to rental being paid
for similar space in the same community
Repairs and/or renovations for rented property should be paid by the landlord. WIC may be charged appropriate operating expense.
Donated space that requires repair and/or renovation should be covered by the State or local agency when possible. WIC may be charged the appropriate operating expense.
The purchase, repair or renovation of real property are capital expenditures that do require prior approval. Only in areas where other options are not available should the State WIC Office approve capital expenditures for the purchase, repair or renovation o f buildings.
I. Cost of rearrangement and alterations of facilities required specifically for the WIC Program are allowable with prior approval. The following information must be sent to the State WIC Office:
a. Provide a narrative description of the rearrangements and/or alterations to be made to the facility. When applicable, include
AD-25

GA WIC PROCEDURES MANUAL FY '96

a floor plan and/or diagram with measurements.

b. Provide an estimate of the cost of the work to be done. Itemize the costs to the maximum extent possible, separating materials (identified as to kind), labor and any other related costs.

c. Indicate the estimated start and completion dates.

d. If the cost of the rearrangements and/or alterations is to be shared with other funding sources, describe in detail the method used to prorate the cost equitably between users.

e. Include a statement certifying that the rearrangements and/or alterations to be made are necessary and reasonable for proper and efficient administration ofthe WIC Program.



Include a statement that procurement was made in accordance

with the provisions of 7 CFR. Part 3016 - Grants and

Assistance OMB Circular, Cooperative Agreements with State

and Local Governments.

Tentative approval will be granted only when an estimate is submitted in order that the bidding process may begin. Once the bids have been received and a vendor selection made, the State WIC Office must be provided with the final amount of expenditures required in order that final approval may be granted.

Maintenance and repair are not considered under this cost category.

2. Ifthe rearrangements and/or alterations are to be made to a privately owned building and the work involves structural modification, installation of plumbing, wiring or ducting, or results in a permanent alteration to the facility, we strongly recommend that written approval be obtained from the lessor. Also, the lessor's letter should reflect any agreement made as to what parts of the rearrangement and/or alteration can be removed on termination of the lease.

A complete physical inventory of all equipment purchased with WIC funds must be conducted, documented on the State Equipment Inventory Form (Attachment AD-12), and submitted to the State WIC Office no later than September 30 ofeach year. This inventory must be completed and submitted,
AD-26

GA WIC PROCEDURES MANUAL FY '96

regardless ofwhether or not equipment was purchased during the year. The staff person conducting the inventory must sign and date the form.

Each item must be recorded with the following information:

1. Inventory Number 2. Equipment Description 3. Serial Number 4. Equipment Location 5. Date of Purchase 6. Purchase Price 7. Percentage ofWIC funds used to purchase equipment
Please refer to the Department of Human Resources Real and ~Persol1a!
Property Management manual to properly dispose those pieces ct cc;:uipI!l::: : that are damaged, deleted or discarded. If the equipment has been stolen, enclose a copy of the police report with the inventory form. All equipment (deleted, damaged, stolen or discarded) should indicate as such on your Equipment Inventory Form (column #4).

WIC purchased equipment reported to be missing must be noted on the Equipment Inventory Form. A notation in the 4th column "Location" should specifY "missing" and the date. An anecdotal note at the bottom of the form (or attachment) should specifY details/comments related to the circumstances. When the equipment is located, an additional anecdotal note at the bottom of the form (or attachment) must be made and corresponding location of the equipment noted accordingly.

Ifthe local agency chooses to use a form other than the State form, the above information must be documented.

VITI.

ALLOCATION OF FUNDS

A. Food Funds

The allocation and reallocation of food funds is based on methodology developed by the WIC Allocation Advisory Committee. This includes an analysis of each district's participation at the beginning of the fiscal year by WIC type, within priority. The projected amount to be spent for the total fiscal year is then calculated and, based on priorities, the committee determines which types will be served. The methodology for allocating food funds is described in the Financial Management Section of the State Plan.

AD-27

GA WIC PROCEDURES MANUAL FY '96

When food money is reallocated, it may be necessary to reallocate administrative funds.

B. Administrative Funds

The allocation of administrative funds is based on an average cost per participant.

First, the cost of State agency operations (State WIC Office and Office of Nutrition) is subtracted from the total administrative grant received from USDA Ofthe remaining funds, additional yearly expenses are deducted from the adjusted administrative balance (indirect cost paid to DHR, ADP contractor fees). The new adjusted balance is then available for statewide District (Local Agency) distribution and is allocated based on a-Statewide average coSt per participant and participation of the last 2 closed out program months.

IX.

FOOD COST PROJECTION REPORT

The Food Cost Projection Report is generated monthly and contains information to assiSt with district caseload management. Please refer to this report for specific figures ofexpenditure information. (See Food Fund Allocation Methodology, State Plan, Financial Section)

x.

PROGRAM INCOME

Any revenue generated as a result of administering the WIC Program is considered Program Income. All Program Income will be used to further program objectives and muSt be added to program budget in accordance with 7 CFR 3016.25 regulations.

AD-28

GA WIC PROCEDURES MANUAL FY '96

SECTION TWO - PROGRAM ADMINISTRATION

I.

RETENTION OF RECORDS

A. Definition of Records

Federal regulations state: "Records shall include, but not be limited to, infonnation pertaining to financial operations, food delivery system, food instrument issuance and inventory, certification, nutrition education, civil rights and fair hearing procedures" [7CFR 246.2S(a)(I)].

State policy memo's from the previous year may be destroyed once the new Procedures Manual has been received, unless otherwise instructed. For
example, FFY '93 Policy Memo's may be destroyed once the ~FFY '94
Procedures Manual has been received.

B. Records and Reports

The Office ofInspector General has been given total access to WIC Program Records since that Office has overall authority and responsibility for the examination of the Food Nutrition Service Program. The WIC Certification file is a piece of documentation for detennining food cost charge. Therefore, certification records when requested must be made available to OIG.

If a certification file does not contain the required information, local agency personnel are required to make available to OIG a medical case record or other documentation which will substantiate that the cost incurred by serving the participant is a proper charge to the WIC Program.

In cases where OIG find that certification data is insufficient, and is denied a=ss to the medical record or other documentation is not made available, a claim will result against the State Agency.

C. Retention Schedule

I. The following documents must be retained for five (S) years, as stated in the DHR Record Retention Policy, issued November 12, 1986:

(I) WIC Assessment/Certification Forms (2) Diet Histories (3) Growth ChartsiWeight Gain Grids

2. The following documents must be retained for three (3) years plus the

AD-29

GA WIC PROCEDURES MANUAL FY '96

current Federal Fiscal Year:

(1) Vendor Monitoring Reports

(2) Computer Generated Voucher Registers

(3) Manual Voucher Inventory Records

(4) Budgets and Expenditure Reports

(5) Time Studies

(6) Contracts

(7) Indirect Cost Plan

(8) Shared Costs Documentation

(9) Turnaround Documents (TAD's)

(1 D) Voucher Cycle Packing List (Beginning Oct. I, 1987)

(11) Fair hearing and civil rights complaints and a11 related

documentation

-~

(12) Federal, State, District, County Audit reports

(13) Copies of manual vouchers

3. The following documents must be retained for one (1) year plus the current year:

Waiting List (see CT-XV)

4. The following documents may be destroyed after the required correction, verification, and reconciliation has been completed: (1) Dual Participation Report* (2) Cumulative Unmatched Redemptions Part 1* (not matched to issuance record) (3) Cumulative Unmatched Redemption Part 2* (not matched to a valid certification record) (4) Batch Control Report (5) Batch Control Form and Module (6) Critical Error Report (7) Cancelled food instruments

*

The original copy of these reports with their manual

reconciliation must be sent to the State WIC Office prior to

destroying. The State WIC Office will maintain these for

three (3) years plus the current Federal Fiscal Year.

5. The following documents will be maintained on microfiche at the State WIC Office for a period of three (3) years plus the current Federal Fiscal Year. These may be destroyed by the local agency when they are no longer useful to district and/or clinics:

AD-3D

GA WIC PROCEDURES MANUAL FY '96 a. Monthly Reconciliation - Emollment Cycle

1.

Alphabetic Master File Listing

2.

Critical Error Report

3.

Emollee Income by Household Size

4.

Grady Hospital Emollee Distribution

5.

Medicaid-Emollee 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-

Part 1

5.

Cumulative Unmatched Redemption Over 30 Days

Based on Certification-Part 2

6.

DU/Clinic Compliance Summary (Conc. Pwdr. RTF)

7.

DU/County Compliance Summary (Conc. Pwdr. RTF)

8.

Dual Participation Report-Part 1

9.

Ethnic (Emollment and) Participation by Priority

Issue. 30 Day and Closeout

10.

Ethnic Participation Summary

11.

Financial and Program Status

12.

Food Cost Allocation (projection)

13.

Food Package Create Report

14.

Food Package Expenditures Report

15.

Infant Formula Rebate Report (Conc. Pwdr. RTF)

16.

Infant Rebate County Summary

AD-31

GA WIC PROCEDURES MANUAL FY '96

17.

Infant Rebate District Unit Summary

18.

Migrant Participation Summary

19.

Migrant (Enrollment and) Participation by Priority

Issue. 30 Day and Closeout

20.

Monthly Report of Food Expenditures Summary

Issue. 30 Day and Closeout

21.

Monthly Report of Food Expenditures by Vouchers

Code Issue 30 Day. Closeout

22.

Participant Totals

23.

Participation Summary by District/Unit

24.

Previously Unmatched Redemptions Which Were

Matched

25.

System Maintenance Indicators

26.

Unmatched Redemptions Report

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 County Food Package Compare

7.

Vendor Exception Report

8.

Vendor Listing

9.

Vendor Update Listing

10.

Vendor Voucher Deviation Report

11.

Voucher Redemption Fluctuation Report

12.

Voucher Variation Report

13.

Voucher by Day Cashed

14.

Vouchers Cashed by Clinics

15.

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 ofa 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 acronym and logo are provided in 42 U.S.C. 1786, 15 U.S.C. 1051 et seq., and 7 CFRPart 246.

AD-32

GA WIC PROCEDURES MANUAL FY '96
It is an on-going policy to discourage industrial use of the WIC acronym and logo on products to avoid certain difficulties that may be encountered.

B. Official Use

Use of the acronym "WIC" and the WIC logo isreserved for the official use ofnational, regional, state and local agencies administering the WIC Program.

FNS instructions and policies restrict use to purposes consistent with the WIC

Program regulations. Materials which display WIC identifiers will be used

primarily for identification, public notification and outreach purposes.

Below is a list of possible use of the WIC acronym and logo. This list is not

inclusive and there may be other WIC ideas. FNS reserves the right to

approve any use of the WIC acronym or logo.

-~

Brochures Bulletins Business Cards (for employees) Cups Directories Food Instruments Forms (i.e. Cert. forms) Guides Immunizations Initiatives

Leaflets Letters Manuals Newspapers Posters Radio and T.V. Announcements Reports Studies T-Shirts

C. Special Use

1. Profit and Non-Profit OrganizationsThe WIC logo and acronym can not be used 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 they produce. 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. Nonprofit 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 State WIC Agency in writing. The written request must include a copy/sample of the way in which the acronym or logo will be used. The State Agency must respond in writing whether such use is authorized.

AD-33

GA WIC PROCEDURES MANUAL FY '96

2. WIC Food Vendors

At the discretion of the State WIC Agency, in a standard contract or agreement a vendor may be 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 ~ uses ofthe WIC acronym or logo; and any uses that are considered inappropriat!: .shall be discontinued. Requestfor use ofthe WIC Acronym or Logo must be made in writing along witha copy/sample ofthe way it will be used. A written response will be issued whether such use is authorized.

D. 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 to injunction and the payment of damages. Any person who is aware of violators should provide the information to the SFP.

m.

LOBBYING RESTRICTIONS

The State/Local Agency must not use federal funds for lobbying for specific federal awards and requires recipients of any federal grants, contracts, loans and cooperative agreements to disclose expenditure made with their own funds for such purposes.

AD-34

GA WIC PROCEDURES MANUAL FY '96 SAMPLE FORMULAS

Attachment AD-I

1. RATE FOR SERVICES PROVIDED (RFS)

The following may be used to compute a RFS:

Step 1. Employee A: (# hrs. worked*) x (hourly pay**) = $(A) Employee B: (# hrs. worked*) x (hourly pay**) = $(B) etc.

Step 2.

$(A) + $(B) + $(C) + $(D)... = $$

Step 3.

$$
# participants*** OR
# assessments***

Rate Per Participant or Assessment (cost per participant or assessment)

*

The source for this data is the time study data collection sheets. Data must be

collected on WIC and non-WIC paid personnel to substantiate all WIC costs,

however, the employees in Step I must be non-WIe paid personnel only.

NOTE: You do not include WIC paid employees when computing a rate for reimbursement because WIC paid employees have already been paid with WIe funds and to include them in the rate would mean paying them twice.

** To Compute an Employee's Hourly Pay:
NOTE: Those employees who receive fringe benefits must have these benefits included in their hourly pay rate.
Step I. Salary x Fringe Benefit Rate = F
Fringe benefits are a percentage ofthe employee's sala.ry. They are the combined total of FICA, retirement, and health insurance. This rate periodically changes and the most current rate should be used.
Step 2. F + Salary = Total Salary (incl. fringe)

AD-35

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-I cont'd

Step 3. Yearly Salarylhours per year = Hourly Rate
Monthly Salarylhours per month =Hourly Rate

*** The source for this data are the ADP Contractor reports. "# assessments" is the total number ofassessments performed during the time study period. "# participants" is the number of participants reported for the time study period.

2. FULL-TIME EOUIVALENTS (FIE's)

The following may be used to compute FTE's:

Step 1. individual's time worked
performing WIC duties x 100% =% oftime spent

individual's total time

performing WIC

worked

duties (P)

Step 2. (P) x (individual's hourly/monthly pay*) = portion of hourly/monthly pay to be reimbursed by WIC.

* Use the same formula used in "Rate" above.

AD-36

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-2

INDEX OF FUNCTIONAL ACTIVITY CODES

A. Physicians: All duties performed in clinic.

B. Midlevel Practitioners: Includes Physician's Assistant, Nurse Practitioner, Certified Nurse Midwife, and Nurses authorized to function in the expanded role. Code by title (not function) except for any time spent in providing ( and recording in patient's medical record) activities listed below under E through H.

C. Nurse - Medical: Includes non-expanded role RN.'s and L.P.N.'s. Code by title (not function) except for any time spent in providing (and recording in patient's medical record) activities listed below under E through H.

D. Medical SUIl,Port (Non-Medical Personnel Only): (Not to be used by M.D.'s, Midlevel Practitioners, and Nurses - Medical). Include time spent providing clinical/clerical support services to medical staff above. (Examples: Time spent by Health Services Technicians in clinical interviewing, weighing patients, setting up the clinic, etc.)

E. Laboratory Services: Time spent performing specific laboratory procedures to provide Diagnostic Services.

F. Pharmacy Services: Time spent by qualified/authorized staff in dispensing medications or supplies.

G. Other Health Services: Time spent providing Family Planning contraceptive counseling, education and outreach, nutrition and other health counseling. Example: Informed consent education, post-exam counseling, referral or follow-up services, time spent pulling/filling patient records, making appointments, following up on missed appointments and all other non-administrative, non-medical activities not included above.

H. Administrative: Time spent in management, evaluation, training, completing statistical reports, medical record audits, screening/billing!collecting fees from patient/medicaid, inventorying!ordering contraceptive supplies, and clerical/typing work not directly supportive of Health Care Services.

I.

Non-Family PlanningINon-WIC: Time spent in functions not related to Family Planning or

WIC.

1. Holidavs Annual/Sick Leave: Use to record any of time in these activities during time study.

K. WIC Administration: Time study activities, grant writing, preparation and maintenance of

AD -37

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-2 cont'd

program management reports, computer system management/maintenance, overseeing food instrument accountability and reconciliation, fiscal management duties, budgeting, monitoring and reviewing expenditures, bookkeeping, payroll, office management, record keeping, personnel actions, leave records, vendor management, outreach activities, legal services, audits and other financial services and clerical support. Planning and training in administrative and ADP areas and audit tracking, batching and mailing Moter-Voter Registration Applications as well as maintaining a file ofMoter-Voter declinations.

L. Client Services: Income screening, completion ofWIC assessment/certification forms, height, weight, hematocrit, plotting growth charts/weight gain grids, program referrals, record retrieval and filing, voucher issuance process, explanation ofWIC-approved foods, dietary recall and assessment (for the purpose of determining eligibility), receiving and resolving participant/vendor complaints, participation in completing surveys and studies which evaluate the impact of WIC on its participants, coordination of services with other-programs, participation in activities which promote a broader range of health and social services for participants, delivery of food and other client services and benefits, assisting clients with Moter-Voter registrations and declinations.

M. WIt Nutrition Education: Nutrition education given during certification, WIC Follow-up nutrition education (secondary contacts). Includes planning and documentation time for nutrition education, dietary recall for the sole purpose of nutrition education (not for determining eligibility), developing materials (includes research and procurement) and nutrition education services. Charge Nutrition Education given in EPSDT, or Family Planning to EPSDT or Family Planning.

N. WIC Breastfeeding Activities: Promotion of breastfeeding classes, individual contacts, planning, documentation and developing materials for supporting the breastfeeding mother.

*

When completed for WIC Eligibility determination only, and not part of another clinic

evaluation (e.g., EPSDT).

NOTE: Prorate WIC travel time to appropriate code (J, K, L or M).

AD-38

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-3

WIC TIME STUDY DATA COLLECTION FORM

... _......-.~~nl/In&lnl_.I_.u:trKtW.

QJ_

_ Illng.pr_atioft_.....-_olpr..... _ _ .--u.

_
~lood_....,...-,.

_ """'tIoc~

..-..-nt __.IA_l><ldQoOIho............-..._~~&.

~ . . . .l ' f t I l l ,

._..-1t:--'

_ _.._ _..... _ _ _ ~oftlcoo---.-.:Ikeept1O

.clioN. _ _dio:

. . . - _ . . . - . .

.... ....._ _ tiMg, ~lQNGalnV"D.Al_

~lI<'d

_ i. - . ""

=-ion ofWIC-_d_.....tory

t.__ u

nt(lor _ _ ofa~~".~MngI

... oMngC6tIIP~tI . , . - , . _.... ....w:.. prov... _ - - .

_ c ..... WIC ..I_-..,"""'.Ion

~eonlKt&)

_1Ity_1or_ . . . ~..-.~_ClO~Il_o"OOlIt.m..o.t.l.a-'-.-...:.i.o...n..~...i.c_Ionnl.rlinll

.1igI:>IlltyJ.-"'pinQ"",,,,,,-(~--~
____ - - . . ...-.-. o-v-t,"*_E-.uon ..... lI'IEl'SOf.
or Family PIaMln\I ",EI"$OT GI FamllyP-.nII>g.

_ _Ioc>ig
_1_to.~_Ion

""

~ ... .... tlr.-.6nCI.....cr-.~ .... ~
_1iIIn.c.tMlilo..._ ....-'. . .

f ...NNUA! tfM'f j'i1S';1C' EAyf 96 HOLIPAY

I

I

AD-39

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-4

WICIFAMILY PLANNING TIME STUDY DATA COLLECTION FORM

- ...!W

,. -Ill[

'7::10 1II

7:46111

.:00 1II

8:16111

.::10 1II

8:46" ':00

9:16 ':30

9:46 10:00
10:16 10:30

10:46
u:oo "
11:16 II U:30" 11:46 II
u:oo It
12:16 It U:30 It
12:46 It 1:00 It 1:16 It 1:30
1:46 2:00
2:16 2'30
2:46 It 3:00 It

3:16 It 3:10 It 3:46 It 4:00 It

4:161' 4::10 II

4:46 It 5:00 II

INS11ttlCnONS

Rcconllime eveJY 15 miJlutei. Record lbc
acMl)' 7"" arc doiDc IU!lulIll or cadl
15 miDuu period..

Ezltirc ~/wee't arc 10 be _llIe,Hor.

TIIIlC speDl in recordiDc iDlormalioD in

palieDl rcconl is 10 be clwJed as pan of

cad> aetml)'. .TUIlC spelll ill recorcliJl&

= raullO of physical

will be eocIed by

or tile title lbc pnMder (Codes A-D).

au:
A

-'1llE:

llI%>

mil

mI ~



C

0

E

F

G

B

I

J

It

L

L

II

~

AD-40

GA WIC PROCEDURES MANUAL FY '96 TIME STUDY SUMMARY

Attachment AD-5

FFY:
,
NAM'

llMe STUDY SUMMARV'

TIME STUDY DATE: OlSif!lCT/UNIT: DATE SENT TO SoIIO:

TITU

3 MONTHLY SAW

.
TOTAL TIME

S
TOTAL
ADMIN

6
"A[J.IIN

TOTAL CS

c"s

TOTAL N.E

""N.E

"TOTAl
a.F.

SlGNATURE:

""aF.

3 COST
OF

"COST OF

,
COST OF

"COST OF

INCRE.

ACT.

ACT.

ACT.

ACT

AWIN U&lTSVC NE

B,F.

--------t------tI--+--+--4---+---!---1---I--+--+--4--+---!-----t----I -.---+-----t--t--t--t--t--I----I----I----j---+---j-----j-----+--j---;
-.---t------+---+--+---/---;I--I---+--I----+--.-/---I----/---t---I--1

EMPLOYEE'S NAME EMPLOPVEE'S JOB TITtE/POSlTlON EMPLOYEE'S MONlHLY SALAAY TOTAL TIME INCREMENTS lOTAlAQMINISTRATIVE ACllVl1lES PERCENTAGE OF ADMINI$TRAnve ACTlVlTlES
TOTALCLlE'NT SERVIce AC'TlVITIES PERCENTAGE OF CLlENT seRVice ACTIVITIeS

= 9 .. TOTAl NUTRITION EDUCATION ACT1Vmes
10 PERCENTAGE OF NUTRIl10N EOUCAllON ACllVlTIeS 11 = TOIAL BREASTfEEOING ACllVITlES 12'" PERcENTAGE OF BREA$TFeeOING ACTIVITIES 13 .. COST 01' AOMINISTRATIVE ACllVllles 14 .. COST OF CUENT SERVICE ACTIVmes 15 .. COST OF NUTRITION EDUCATION ACTMTlES
16 .. COST 01' BREASTFEEOING ACTIVITIES

AD -41

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-6

Information Needed for USDA Approval of Non-Major ADP Equipment.

1. Description ofthe ADP equipment to be purchased and the anticipated cost. Ifthe cost is not to be borne solely by federal WIC administrative funds, the funding sources should be itemized.

2. Identification of the intended user(s).

3. Explanation of the program functions which the ADP equipment would perform.

a. The explanation must be detailed and specific.

b. If the equipment is not to be used solely for WIC administration/operations, the

application must demonstrate that its used for WIC purposes will be commensurate

with WIC participation in its costs.

-:

4. Explanation of the cost benefits the local agency anticipates will result from the acquisition ofthe ADP equipment (such as reduced costs per certification.) The explanation must show:

a. Why management information systems already in place (such as the state food delivery ADP system) cannot meet the need which the local agency is proposing to acquire additional ADP equipment.

b. The local agency has considered all possible options and identified the proposed ADP acquisitions as the most cost effective. Example of options the local agency should consider might include:

1. performing the functions manually; 2. arranging for the function(s) to be performed by a contractor, by the state
agency, or by another unit of the local agency; 3. purchasing other types of ADP equipment.

5. Explanation ofhow the proposed ADP acquisition conforms to an overall long range plan for the acquisition and use of ADP hardware, software, and services.

6. Certification that the procurement methods are in compliance with state purchasing regulations.

AD-42

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-7

MEMORANDUM OF UNDERSTANDING BETWEEN
STATE AND LOCAL AGENCIES FOR
THE SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WlC)

This provider agreement is made pursuant to the Georgia Department of Human Resources Administrative Policy and Procedures Manual, Part II A.I., Administration of Grants and USDAlFNS 7 GFR 246.6, Agreements with Local Agencies. This agreement is between the Georgia Department of Human Resources, DMsion of Public Health and the District Health Program (hereinafter referred to as the Local &.lency) names on page IV of this agreement. This agreement is made effective the first day of October, 199$ and shall continue for one (1) year unless revised or terminated as provided herein.

THE STATE AND LOCAL AGENCY AGREE:

1.

To abide and comply with the Georgia DHR Administrative Policy and Procedures and DHR

Grants-to-Gounties Policies for administration of funds.

2.

To collect data as required by USDA and State regulations and requests to insure

confidentiality of ali such information in accordance with the State's confidentiality

requirements.

3.

To further abide and comply with USDA program regulations 7 GFR 246 and State policies

and procedures as outlined in the State Plan of Operation.

THE STATE AGENCY AGREES:

1.

To make administrative funds available on a monthly basis for use by the Local Agency in

meeting all allowable administrative, nutrition education, and breastfeeding project expenses

of the WIG Program as evidenced by documented costs.

2.

To make food funds available in the amount allocated to the Local Agency for vouchers issued

to eligible participants and processed through the WIG bank account.

3.

To monitor and evaluate the Local Agency to insure maximum effectiveness and efficiency;

to provide technical assistance and consultation; and to provide training for Local Agency staff

on a routine basis and as requested.

4.

To provide all manuals, forms, and materials reqUired for operation of the WIG Program or

specified in the State Plan of Operation.

THE LOCAL AGENCY AGREES:

1.

To hire and train competent professionals and clerical staff to carry out WIG responsibilities:

and to provide necessary facilities, equipment and training to perform WIG assessment and

certification procedures. WIG assessments must be performed by competent professional

authorities.

2.

To make appropriate health services available to participants up to the income level specified

for the WIC Program; and to inform applicants of the health and social services which are

available.

AD-43

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-7

3.

To implement the Food Delivery System agreed upon between the State and Local Agency,

under terms prescribed by the state Agency as necessary to implement a uniform system in

accordance with WIC regulations and approved by FNS. The Local Agency will execute an

Agreementwith all vendors providing WIC foods in the local service area in accordance with

FNS and State Agency instructions. The Local Agency will monitor participating vendors in

accordance with the terms of the Vendor Provider Agreement.

4.

To maintain and have available for review, audit, and evaluation all criteria used for

certification including information on the areas served, income standards used, and specific

criteria used to determine nutritional risk.

5.

To develop and submit an annual Local Agency Nutrition Education Plan consistent with the

nutrition education portion of the State Plan and in accordance with WIC regulations 246.11

(d) (2) and FNS guidelines.

6.

To develop and submit an annual Local Agency Breastfeeding Promotion Plan-:- :

7.

To develop and submit an annual Local Agency ImmunizationlWlC Collaboration Action Plan.

8.

To develop and submit an annual Local agency Action Plan for the early enrollment of

pregnant women.

9.

To maintain complete and accurate documentation, and current accounting for all WIC

administrative, nutrition education, and breastfeeding funds received and expended; and to

make these records available for audit upon request of the State or Federal Agency. In the

case of an audit exception in administrative, nutrition and breastfeeding education funds, the

Local Agency will be responsible for repayment to the State Agencv.

10. To ensure timely submission of responses to all required and requested program information including but not limited to reports, program reviews, policy, action and information memorandums. When warranted, corrective action plans must be developed and implemented to correct program deficiencies in accordance to state policies and procedural guidelines.

11. To ensure that food expenditures will be monitored through the use of automated system reports and on-site program evaluation. Local Agency food allocations will be reduced by the dollar value of vouchers issued to ineligible participants based upon findings of the program evaluation.

12. To implement a security system for unissued food instruments (vouchers) which will protect from and reduce the risk of on-site lost/stolen vouchers. In the event that unissued 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.

13. To provide nutrition education services to participants in compliance with 7 CFR 246.11 and FNS and State guidelines and instructions.

14. To conduct self-reviews annually for evaluation of local program operations and ass.essments of program accomplishments in accordance with WlC Regulations Subpart F 246.19(b)(6) and the state guidelines for program monitoring. Documentation of reviews will be maintained and made available for program audit purposes.

AD-44

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-7

15. To ensure that no employee nor applicant for employment will be discriminated against on the basis of race, color, national origin, age, sex, or handicap.

16. To comply with Trtle VI of the CMI Rights Act of 1964 (p.L. 88-352) and all requirements imposed by the regulations of the Department of Agriculture (l CAR Part 15), Department of Justice (28 CAR parts 42 and 50), and FNS directives or regulations issued pursuant to that
Act, and the regulations; to the effect that, no person in the United states shall on the ground
of race, color, national origin, age, sex or handicap be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination under any program or actMty for which the program applicant received Federal financial assistance from the Department; and hereby gives assurance that it will immediately lake any measures necessary to effectuate this agreement.

17. To conduct Public Hearings in local service area in accordance with WIC Regulations CFR 246 Subpart B 246.4. The Public Hearings solicit public comments on the State Plan, and give local citizens an opportunity to comment on services provided to them. Correspondence
announcing the Public Hearing must be made available to the general public, '1:0 special
interest groups and to organizations serving significant numbers of eligible persons. All Public Hearings must be completed by April 30 each year, and proceedings from the hearings must be submitted to the Slate WIC Office by June 1 for inclusion in the State Plan.
18. To make available to OIG all medical records or other documentation which will substantiate the cost incurred by serving WIC participants.

~

To comply with basic requirements for local agency participation in the development of the

State Plan consistent with WlC Regulations 19 246 Subpart B. The Local Agency will develop

and submit for inclusion in the State Plan an annual program plan. By June 1 each year, the

Local Agency shall submit a program plan to the State WIC Office. The plan must include but

is not limited to: a narrative summary of program objectives and accomplishments for the

preceding fiscal year; objectives and interventions to improve and/or expand WIC operation

and administration for the coming fiscal year. Objectives must be developed in accordance

with the following program functions: Programmatic Administration; Food Instrument

Accountability; Vendor Management; System Information Management; Financial

Management; Quality Improvement; and Program Intervention.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants, and loans of Federal funds, reimbursable expenditures, grant, 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 in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the program applicant by the Department. 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.

AD-45

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-7

By accepting this assurance, the program applicant agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement ofTille VI and to permit authorized USDA personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with Tille VI. Ifthere are any violations ofthis assiJrance, the Department of Agriculture, Food and Nutrition Service, 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 received assistance or retains possession of any assistance from the Department. The person or persons whose signatures appear below are authorized to sign this assurance on the behalf of the program applicant.

This provider agreement may be terminated by either party upon sixty (60) days written notice. Non-renewal of this provider agreement is not cause for appeal.

The Local Agency has the right to appeal decisions of the State Agency which affect program participation as specified in 7 CFR 246.24, Administrative Appeals. A Local Agency is allowed two (2) opportunities to reschedule a hearing.

Patrick Meehan, M.D., M.P.H. Director
Division of Public Health or designated repres!lntative

DATE:

_

District Health Director or the designated representative acting collectively for the Counties in District_, Unit_
DATE:

AD-46

GA WIC PROCEDURES MANUAL FY '96 CONTRACT BUDGET

Contract '~rtod

A. Pc"MM.l Services .$clartu FrtftgCHMflts Other

I. ~ltn

C. '''''f1UfIg

D. q"t~"t OffIce
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r. Trawel

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Attachment AD-8
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ttlis contt'W aha11 IlOt eaceed ttw ..at.s estAltshld I.. the

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AD-47

GA WIC PROCEDURES MANUAL FY '96 MONTHLY EXPENDITURE REPORT

Attachment AD-9

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AD-48

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-I 0

WIC FORMS AVAILABLE IN CENTRAL SUPPLY

Contact:

Cindy Woods

(404) 657-2900 or GIST 294-2900

FORM NAME

1. Georgia Department of Human Resources Division of Public HealtbfWIC Program I.D. Card - Box/500

t~j!II~~]\i~j7g~ (English)#3769 (Rev. 8-88)

2. Georgia Department of Human Resources

Division ofPublic HealtbfWIC Program

Rights and Obligations - Pad/IOO

(English) #3768 - (Spanish) #3766 (Rev. 6-91)

3. Georgia Department of Human Resources Division ofPublic HealtbfWIC Program WlC Assessment/Certification Form Women - Pad/IOO

#3296 (Rev. 8-89)

4. Georgia Department of Human Resources Division of Public HealtbfWIC Program WlC Assessment/Certification Form Infants - Pad/IOO

#3299 (Rev. 8-89)

5. Georgia Department of Human Resources Division of Public HealtbfWIC Program WlC Assessment/Certification Form Children - Pad/IOO

#3285 (Rev. 8-89)

6. Georgia Department of Human Resources Division of Public HealtbfWIC Program Batch Control Form - Pad/IOO

#3762 (Rev. 11-89)

7. Georgia Department of Human Resources Division of Public HealtbfWIC Program Invalid Participant ID Correction Form - Pkg/250

. #3763 (RevA-86)

AD-49

GA WIC PROCEDURES MANUAL FY '96

8. Georgia Department of Human Resources
Division ofPublic Health/WIC Program Notice ofTerrnination/Ineligibility/Waiting List - Pkg/250 I.~i.iigi (English)#3293 (Rev. 11-90)

9. Georgia Department of Human Resources Division of Public Health/WIC Program Food List Brochure - Pkg/IOO

#3777 (Rev. 10/93)

10. Georgia Department of Human Resources Division of Public Health/WIC Program Food List Stickers - Pkg/250

. #3778 (Rev. 6/93)

11. Georgia Department of Human Resources

Division of Public Health/WIC Program

WIC Outreach Card (Large)

" (English) #3765 - (Spanish) #3754 (Rev. 7-91)

12. Georgia Department ofHillnan Resources Division of Public Health/WIC Program WIC Outreach Card (Small)

#3752

13. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Outreach FlyerlPoster

(English) #3749 - (Spanish) #3733

14. Georgia Department of Human Resources Division ofPublic Health/WIC Program Georgia WIC Resource Referral Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. #3297

AD-50

GA WIC PROCEDURES MANUAL FY '96

Attachment AD-II

NUTRITION MATERIALS AVAILABLE IN CENTRAL SUPPLY

Contact: Kathryn Thompson (404) 657-2884 or GIST 294-2884

1. WOMEN

Good Beginnings (English & Spanish) Building Blood (English & Spanish) Your Daily Food Guide (English) Weight Control (English) Exercise Away Your Calories (English) Guide to Good Eating (English & Spanish) Nutrition for the New Mom (English & Spanish) Breastfeeding Near to the Heart (English & Spanish) Breastfeeding Doesn't Have To Be Embarrassing (English) Breastfeeding Can Make Baby's Father More Loving (English) Breastfeeding Can Make Grandmothers More Loving (English) Breastfeeding Can Help You Bond With Baby (English) Breastfeeding Is Easy to Learn (English) Breastfeeding Can Make You Feel Good About Yourself (English) Breastfeeding Can Make Your Family Proud (English) Breastfeeding Doesn't Keep You From Doing What You Want (English) Breastfeeding Doesn't Have To Tie You Down (English) Breastfeeding Doesn't Change the Way You Eat (English)

2. INFANTS

Food For Baby's First Year (English & Spanish) Feeding Your Growing Baby (English & Spanish) Put Your Child To Bed With a Teddy Bear (English & Spanish)

3. CHILDREN

Food For Children 1-5 (English & Spanish) Trim & Fit Kids (English & Spanish) Good Snacks For Kids (English & Spanish) About Good Nutrition (English)

*This list is not inclusive of all available materials. Contact OON for additional items.

AD - 51

GA WIC PROCEDURES MANUAL FY '96
EOUWMENT~NTORYFORM

Attachment AD-12

EA ~ DISTRICT:
IHVEH'rORY I<lJIiBER

>fIC PROCRJ\Jl l:OUIPIIEIlT IHVEH'rORY (3 Year LiCe l:xpecuncy And $100 Or Above,

Dl:SClUPrION

SERIAL IDCATION PURCHASE I'IIRCllAS WIC FUNDS

I<lJIiBER

PRICE

DATE EXPENDED

~

Inventory CcIDpleted By:

----

Date:

_

AD-52

GA WIC PROCEDURES MANUAL FY '96
I. INTRODUCTION
The retail grocery vendor plays a major role in the success of the WIC Program. The vendors must assure that the correct foods are purchased by the participants. Prices charged by vendors must be reasonable and competitive, thus allowing the WIC Program to serve a greater number of indigent women, infants and children in Georgia. The guidelines set forth in this section are to assure Program success through Federal and State Program requirements.
II. VENDOR COORDINATOR
It is the responsibility ofthe local agency to designate one person to act as the local Vendor Coordinator. This person will be responsible for all local agency vendor activities and will be the primary contact person for the vendors in the district
IlL ENROLLMENT OF NEW VENDORS
A Selection of Vendors
L Any merchant expressing an interest in participating in the WIC Programwill be sent a Vendor Application Booklet (Attachment VN-l), in91Ys!ing,WJ:I1JlPJiS!!!!QH for Vendor Certification (Attachment VN-2). Applications ?~!~i~t~~!!l@~t!& and should be received by the local agency no later than 4:QQp,lIl.th(lfirgAl'iY9f
~~~i'.ifanuary 2, April I, July I, and October 1);llj~'Pfm!!~~~!{j4mng
Local Agencies may consider using Attachment VN-20, which is a typical form letter that should accompany the application packet
2. The local agency representative will visit the store and complete the Vendor Review Form (Attachment VN-I6). The Vendor Application and the Vendor Review Form must be submitted to the State WIC Office by the end of the first month of each quarter (January 31, April 30, July 31, October 31).
3. The State WIC Office will approve or disapprove all Vendor Applications by the 15th of the second month of each quarter (February 15, May IS, August 15, November, 15).
When a Vendor Application is approved, the State WIC Office will complete the Vendor InputlRegistration form to update the system. A copy of the Vendor InputJRegistration form will be submitted to the local agency along with the
VN -I

GA WIC PROCEDURES MANUAL FY '96
assigned vendor stamps. The local agency will issue one vendor stamp to the vendor and give the approptiate .training,.as stated on page VN-3. Approval criteria are discussed on the following page.
When a Vendor Application is not approved, the State WIC Office will write a letter to the vendor explaining the reasons for disapproval. The merchant can correct the reasons for disapproval and reapply for WIC participation by the next application deadline. However, the State WIC Office has the authority to deny a vendor applicant from WIC Program participation, if the applicant previously was an authorized vendor/manager that voluntarily withdrew from WIC Program participation with one or more types of the following derogatory standings:
- High risk according to the state agency's high risk indicator - Abusive by state agency's outlined sanctions - Food Stamp Program disqualification
4. Action will be taken on all Vendor Applications within 45 days from the first day of each quarter (January, Apri~ July, and October).
B. Approval Criteria for Vendors
Approval by the State WIC Office for vendors appl~&[gr,YJIC Program participation will be based on the selection criteria listed in the Nt~n4Qt Application Booklet (see Attachment VN-I).
Upon the purchase of a previous WIC approved store or in case of changing ownership of a previous WIC authorized store, the new vendor applicant must submit to the State WIC office proofthat a legitimate or valid bill of sale took place between both parties by complying with the Bulk Sale Law of Georgia (see Georgia Official Code Annotated for Law).
Also, the following price comparison criteria will be used for all vendors applying for WIC authorization. The process for defining the price comparison is as follows:
Every vendor's prices will be compared to the statewide standard maximum prices. Prices must not exceed 10% above the state average for small stores/peer group 1. Also, this criteria must be met in order to renew a vendor's contract. Groups are categorized according to the square footage and/or type ofstore. The vendor type noted on the input form will identifY each group. This field is designated for initial certification and must be filled out only by the State WIC Office. Do
VN-2

GA WIC PROCEDURES MANUAL FY '96

not complete the vendor type when completing an input form (Attachment VN-3).

The following is a list of vendor group codes, square footage, and store size:

Group Code! Vendor Type Code

0-5,000

2

5,001 - 10,000

3

10,001 - 15,000

4

15 001 OR MORE

5

6

7

C. Authorization and Reauthorization
Authorization and reauthorization, induding exceptions to the approval criteria, will be made by the State WIC Office only. Reports used to determine certification are listed in the State Plan. The same price comparison criteria required for original approval must be met for reauthorization of an existing vendor.
IV. VENDOR STAMP
The State WIC Office will provide the local agency with two (2) vendor stamps at the initial certification of the vendor. It is the responsibility of the local agency to replace lost or damaged vendor stamps. When a replacement or additional stamp is issued to a vendor, the State WIe Office should be notified.

VN-3

GA WIC PROCEDURES MANUAL FY '96
VENDOR AGREEMENTS
Once a store has been approved for participation in the WIC Program, a Vendor-Agreement (Attachment VN-4) must be signed between the WIC local agency and the new vendorThe contract year for a Vendor Agreement is October I through September 30_ A new Vendor Agreement must be signed by October I of each year in order for a vendor to be authorized to accept WIC vouchers. The local agency will be responsible for retrieving vendor stamps from any vendor that does not sign an agreement by the specified date. Vendors who do not sign a new Vendor Agreement within the specified time period may reapply during the next quarter for WIC authorization.
Military commissaries must sign the Military Commissary Agreement (Attachment VN-5).
p.harmacies are.l:l"l<:~ptfrom the minimum inventory requirements. Pharmacies must sign
~l Pharmacy II.i~~i,(Attachment VN-6).
Rolling stores must sign an Addendum to the Vendor Agreement (Attachment VN-7), as well as the :Vendor Agreement, and submit a Route Schedule (Attachment VN-8). The State WIC "Office will mail route schedule forms to each roIling store vendor each quarterThis route schedule must be returned on Nov. 15, Feb. 15, May 15, and Aug. 15 of each year.
The Vendor Agreement must be signed by the store owner or the store manager who is legally responsible for the store. Ifthe store manager signs the Agreement and later leaves the store, a new Vendor Agreement must be signed by the new store manager- The vendor stamp number will remain the same.
A copy ofthe Vendor Agreement (new vendors) IDllst be submitted to the State WIC Office within thirty (30) days from the date the contract is signed. Vendor Agreements, to renew current vendors, must be received no later than November 1 of each year.
When Vendor Agreements are not received within these specified time frames, the State WIC Office will proceed as follows:
1. After thirty (30) days, a phone call will be made to the Vendor Coordinator-
2. After sixty (60) days, a letter will be sent to the WIC Program Coordinator-
3. After ninety (90) days, a letter will be sent to the Health Officer-
4. After 120 days, a letter will be sent to the vendor, notifYing him that his store is
VN-4

GA WIC PROCEDURES MANUAL FY '96

not authorized to participate in the WIC Program.

After Vendor Agreements are signed and forwarded to the State WIC Office, within 30

days from

WIC Office will submit to each District a list of Vendor

Agreement(s)

received.

When a store name changes and the owner remains the same, the local agency must have a new Vendor Agreement signed, update the system with a name change and submit a copy of the Vendor InputlRegistration form to the State WIC Office. Vendor type should not be completed; this field is for State WIC Office use only.

When ownership changes, even if the store manager does not change, an application for vendor authorization must be completed by the new owner. The vendor stamp must be retrieved from the previous owner at the time the ownership changes. A new number will be issued to the new owner upon application approval (see VN-2 for Approval Criteria for Vendors) by the State WIC Office. Anew Vendor Agreement must be signed by the new owner.

WIC vouchers must not be accepted by a new owner during the processing time for a change of ownership. If, for any reason, the store is not approved for WIC participation, the vendor will not be paid for any vouchers the store has redeemed. Should there be a delay in processing the application and the new owner is in possession of stale dated vouchers, the vendor will not be paid for those vouchers. Vendor Agreements must be signed and vendor stamps must be issued prior to vouchers being accepted.

VENDOR TRAINING

All new vendors must be trained prior to accepting any WIC vouchers. The training should include the following, at a minimum:
1. Vendor Agreement provisions 2. Processing WIC vouchers 3. Bank return policy 4. Approved W1C foods 5. Vendor administrative procedures 6. Vendor monitoring 7. Sanction point system 8. Vendor disqualification (WIC and Food Stamp)
VN - 5

GA WIC PROCEDURES MANUAL FY '96

9. Fair hearing procedures 10. Vendor reauthorization II. Any changes in procedures pertaining to or affecting vendors.

Included i vendor

process, for the convenience of the vendor, is a cashiers

trammg. This

gives detailed instructions on how cashiers should redeem

and process WIC vouchers (Attachment VN-13).

All vendors must be trained at least once per year. All training must be documented, using

the Vendor Training Checklist Attachment VN-9), Vendor Training Inforillllti

rm

(Attachment VN-IO

. -In Sheet (Attachment VN-II .

The Vendor Training Checklist must be completed by the vendor at the end of each training session and submitted to the State WIC Office attached to the Vendor Agreement.

The Vendor Training Information Form must be completed after the final training session

in each district unit. This form will indicate which vendors did not attend training, but later

signed a Vel).dor Agreement. The local agency should allow vendors a grace pe!1Q4,?fl~n

nQ) wor '.

ttend the District/Unit make-up training session prior to ~m~~m~~f

It will also indicate which vendors did not renew their Vendor

Agreement. Those vendors who do not renew their annual agreement will be terminated

from the Program. A copy ofthis form, along with a copy ofthe Vendor Input/Registration

form for terminated vendors and the vendor stamp(s), must be sent to the State WIC Office

within thirty (30) days after the final training session.

The Vendor iKiMSign-In Sheet should be used for all group trainings and a copy must be submitted to the State WIC Office within thirty (30) days after the final training session. The local agency may ask to view the manager/owner pictured identification card to ascertain that the person signing in for training is legally"responsible for the store.

Vendor Handbooks (Attachment VN-12) must be provided to vendors.

VN -6

GA WIC PROCEDURES MANUAL FY '96

VENDOR MATERIALS

The following materials are available from the State WIC Office for vendor training and store use:

-ShelfMarkers/Stickers -

ls A WIC Food

-WIC Cashiers Training Pamphlet

-Window Poster - We Welcome WIC Customers

-WIC Approved Food Picture Pamphlets (English and Spanish)

-WIC Approved Food Poster

-Vendor Agreements

-Vendor Training Check-List -Rolling Store Route Schedule -Rolling Store Addendum -Vendor Review Form -Application for Vendor Certification Form -Return Voucher Payment Form (Log) -Vendor Handbook

-Vendor Application Booklet -Vendor Information Training Form -Vendor Training Sign-In Sheet

System Form
-Incident/Complaint Form
These materials can be ordered through the State WIC Office.
Also, the State WIC Office will distribute to Local Agencies, the Voucher Exception Summary Report and highlight the information that indicates the number of vouchers that were flagged due to stale dating, post dating, and exceeding the voucher maximum. This

VN-7

GA WIC PROCEDURES MANUAL FY '96
report should be used as a training tool during vendor training.
MONITORING
A. Vendor Monitoring Procedures
All vendors must receive an on site visit at least once every two (2) Federal Fiscal years. A minimum of one half of a district's vendors must be visited each year. The Vendor Review Form (Attachment VN-16) must be used for monitoring visits. (Attachment VN-17, provides instructions for completing the form.) The following procedures must be used when monitoring vendors:
I. Each visit must be unannounced. 2. Introduce yourselfto the store owner or manager and explain the purpose of your
visit. 3. Complete the monitoring form, which will include recording vendors' compliance
with minimum inventory requirements and recording of vendors' shelf price infQrmation. 4. Review vendors' on hand vouchers for proper redemption procedures (i.e.
5. rsirgnatures, p.urch.ase amount, and voucher use/dep.osit dates).
6.
7. Give a copy of the form to the vendor. 8. Send a copy of the form to the State WIC Office.
The State WIC Office will review the form, assign sanction points for violations when applicable, and notify the vendor ofthe sanction points issued.
If violations are found during a monitoring visit (excluding new vendor reviews), another visit should be made within sixty (60) days to determine ifthe violation(s) have been corrected. If the violation(s) have not been corrected, additional sanction points will be assigned.
By March I of each FFY, the State WIC Office will submit to each District Office a list ofvendors who were not monitored during the previous year. This will assist the District Office in planning the monitoring prior to annual vendor training.
By August I of each FFY, the State WIC Office will submit to each District Office a list of vendors who have been monitored and the percentage of vendors monitored FFY-to-date. This procedure will provide Districts with information that will assure
VN -8

GA WIC PROCEDURES MANUAL FY '96
that all vendors are monitored by September 30, every two (2) years. The State WIC Office will provide information to the District Office related to whether or not follow-up monitoring visits occurred within 60 days after violation letters are received by the Local Agency. B. Local Agency Monitoring Procedures The Local Agency Monitoring Tool shall be used to monitor vendor activities (see Monitoring Section, Local Agency Monitoring Tool). This tool has been incorporated into the Local Agency program review process to evaluate the Local Agency vendor management practices and compliance with Federal Regulations and State Policies and Procedures, relating to vendor activities.
~.
State WIC Office Procedures Prior to District Vendor Management Review A random selection of vendors will be made by the State WIC Office prior to the District Vendor Review. The percentage ofvendors to be reviewed will be determined by the State WIC Office.
VN-9

GA WIC PROCEDURES MANUAL FY '96

The State WIC office will assemble pertinent information concerning vendor operations
in the District prior to the review,whi<;h may include the following:
* Bank reports related to rejected vouchers * VA1I1P Reports of problem vendors * Complaints and other problem areas identified

The State WIC Office will provide information to the District related to records and other items that will be reviewed during the visit.

State WIC Office Interim Procedures of District Vendor Management Review

With the assistance ofthe WIC ProgramNendor Coordinator, the State Reviewer shall identifY high risk vendors, through the evaluation of VA1I1P Reports. Once the high risk vendors are identified, the reviewer will conduct unannounced vendor monitoring visits. (Depending upon the number ofhigh risk vendors, Local Agency assistance may be required.)

Local ~gencies Responsibilities

Local Agencies should prepare a file for each vendor, inclusive of at least the following

infor

.

ill

* Store Manager/Owner Signed Vendor Agreements (three years prior, plus the
current year)

* Store Manager/Owner Signed Vendor Training Checklist (three years prior, plus
the current year)

* Monitoring Forms within past three years, plus the current year
* Vendor Activity Monitoring Profile * Copies of Participant Complaints that involve vendors (when applicable) * Correspondence copies forwarded to the Local Agency in reference to their
district's specific vendors

* Copies of Vendor InputlRegistration forms sent to ADP Contractor and State
WIC 0 ce

Local Agencies must conduct on site vendor monitoring for half of the vendors per year to assure that all vendors are monitored every two years. Local Agencies must make site visits to all new vendors within 60 days after approval. The Local Agency Representative must utilize the review form to identifY if additional
VN -10

GA WIC PROCEDURES MANUAL FY '96

sanction points. Also, the use of the Annual is opti.Qna! to examine vendor/cashier training needs.

Follow-up monitoring visits must take place within 60 days if a store does not have minimum inventory following a Local Agency vendor review.

The Local Agency must establish a vendor application file that includes all pending vendor applications.

Xl. COMPLIANCE INVESTIGATIONS

Compliance investigations will be coordinated by the Quality Improvement Unit of the State WIC Office (Refer to Quality Improvement Section of the Manual).

VENDOR SANCTIONS

Any WIC vendor found to be in violation of Program policy and/or regulations will be assessed a p.oint value consistent with the severity of the violation. Each violation of Program pblicy and/or regulations has a set point value and a specific time period during which the points will remain on the vendor's record.

All points earned are retained on the vendor file for a period of one (I) year. Points will "roll-off" one (1) year from the date of receipt. When a vendor accumulates twenty-five (25) or more sanction points, the store shall be disqualified from the WIC Program, with potential disqualification from the Food Stamp Program. The period of disqualification is determined by the nature of the violations, the number of violations, and past disqualifications.

The actual disqualifi

.ods are determined using the same formula for every vendor.

A description ofthe

point system and how it works can be foul).c,t!?n page VN-56

of the Vendor Handbook (Attachment VN-12) and the Sanction B.'System Form

(Attachment VN-21).

PARTICIPANT COMPLAINTS

All complaints made by a participant against a grocery store must be documented using the

Incident/Complaint Form (Attachment VN-18). Participants may choose not to gi

.

~~r:I~~ copies of this form should be mailed to the appropriate agencies (i.e., .. ~G@ffi,~, State WIC Office).

In the event an immediate resolution is not reached, the Local Agency must update the State

VN -11

GA WIC PROCEDURES MANUAL FY '96
WlC Office of all unresolved complaints and vice versa. Documentation of all complaints must remain on file in accordance with the program record retention policy.
TERMINATIONSIDISOUALIFICATIONS
Vendors that voluntarily withdraw, sell their businesses, or do not renew their Vendor Agreement, are to be terminated by the local agency. Terminated vendors must be notified, in writing, ofthe date of termination and the approximate date the vendor stamp(s) will be picked up. Notification can be given in training announcements when applicable. A separate letter of termination must be used for all other terminations.
The local agency is responsible for completing the Vendor InputlRegistration form to terminate vendors from the ADP Contractor. When completing the Vendor InputlRegistration form, do not enter the vendor type. This field is for initial certification only and will be completed by the State WlC Office.
A copy ofthe termination letter, Vendor InputIRegiStration form, and vendor stamp(s) must be sent to the State WlC Office within thirty (30) days of termination. Also, the District Office must submit InputlVendor Registration forms to the State WlC Office within thirty (30) days of disqualification ofvendors.
Every six months, the State WlC Office will distribute to the District Offices a vendor activity report to update the District of outstanding Vendor InputlRegistration forms. The District Office should utilize this report to identifY ifthere are errors or terminated vendors listed. Ifthere are errors, the District Office will utilize the Vendor InputlRegistration form to make all corrections. Copies must be forwarded to the State WIC office and the ADP Contractor, unless directed otherwise by the State. Any vendor disqualified from WIC may be disqualified from the Food Stamp Program. Vendors who are being disqualified will be notified in writing, at least fifteen (15) days before termination. The notice will include reasons for the action and the right to a fair hearing. When a vendor is disqualified, the local agency will retrieve the vendor stamps and submit them to the State WIC Office.
Ifa vendor stamp cannot be retrieved because of a store fire, theft, or the manager/owner was unable to be located, submit the Vendor InputlRegistration form to the State WIC Office with a statement noting the reason why the stamp is not being returned.
All vendor disqualifications will be made by the State WIC Office. Disqualifications will be based on the sanction point system, compliance investigations, Food Stamp Program disqualifications, etc. Any vendor disqualified from WIC may be disqualified from the Food Stamp Program. Vendors who are being disqualified will be notified in writing, at least fifteen (15) days before termination. The notice will include reasons for the action and the
VN-12

GA WIC PROCEDURES MANUAL FY '96
right to a fair hearing. When a vendor is disqualified, the local agency will retrieve the vendor stamps and submit them to the.State WIC Office.
Probation Period and Hardship Cases
If the manager who is legally responsible for the operation of a WIC approved store is different from the manager who received the maximum amount of sanction points for disqualification, the State WIC Agency may grant a probationary period. The Probationary Period shall be for the same period of disqualification. A probationary period can be granted only once per authorized WIC vendor.
In addition, ifdisqualifYing a vendor causes hardship to WIC participants, the vendor shall be granted a probationary period. A hardship case is granted only when the nearest authorized WIC vendor is ten (10) miles or more away from the nearest WIC clinic. Ifa violation occurs within the probationary period, the vendor shall be disqualified for the full disqualification period. During' a vendor's probationary period, the state has an opportunity to recruit additional retailers in the area to become authorized WIC vendors, in the event that the vendor who is on probation violates his/her probation agreement.
Verification ofparticipant hardship must be conducted by the WIC Vendor Coordinator or designee and determined by the State Agency. The WIC Vendor Coordinator must complete the "Verification Form" (Attachment QI-8) which will be used to determine if a disqualified vendor will create hardship to WIC participants within the District Unit. This form shall be received by the State Agency ten (10) working days after receipt of the correspondence copy of a vendor disqualification letter, and no later than five (5) working days prior to an administrative hearing for a disqualified vendor appellant.
VENDOR FAffi HEARING PROCEDURES
Vendors may appeal decisions ofthe State WIC Office or local agency when application to participate in the WIC Program is denied, when participation is terminated, or when other actions are taken which adversely affect the vendor's participation in the Program.
A vendor must submit a written request for a fair hearing to the State WIC Office within fifteen (15) days from the date of notification of an adverse action they wish to appeal.
The State WIC Office will schedule a hearing date within forty-five (45) days of the hearing request. The vendor will be notified of the time and place fifteen (15) days prior to the fair hearing date. All hearings will be held in the county where the vendor's store is located.
VN-13

GA WIC PROCEDURES MANUAL FY '96
The proposed adverse action must be postponed from the time an administrative fair hearing is requested until a decision is reached .by .the Administrative Hearing Officer. Vendor hearings may be rescheduled one (I) time by the vendor or the State WIC Office.
The vendor will have ample opportunity to present his case at the hearing, including the opportunity to confront and cross-examine adverse witnesses. The vendor may be represented by counsel, if desired. The appellant may review the case file prior to the hearing.
The hearing officer shall be an attorney, retained by the State WIC Office, who is an impartial decision maker with no personal involvement or interest in the outcome of the hearing. The hearing officer's decision shall rest solely on the evidence presented at the hearing and the statutory and regulatory provisions governing the Program. The basis for the decision shall be stated in writing, although it need not amount to a full opinion or contain formal findings offact and conclusions oflaw.
The State WIC Office shall provide written notification of the decision to the vendor within sixty (60) days from the date of the original request for a hearing.
The vendor must continue to comply with all written agreements if Program participation continues during the appeal process.
The State WIC Office will explain any additional appeal mechanism upon request, including the right to a judicial review. If a vendor desires to appeal after an administrative hearing decision has been granted in the State's favor, the vendor must follow the provisions of the Georgia Administrative Procedure Act (Code Section 50-13-16 and 50-13-17).
HIGH RISK VENDOR IDENTIFICATION
Vendor Activity Monitoring Profile (VAMP)
Georgia WIC voucher redemptions are analyzed monthly by the contracted automated Data Processing System. This VAMP system tracks the activity ofWIC vouchers and formulates detailed summary information through analysis ofthe voucher activity (data). Vendors that exemplify high average value for vouchers redeemed or an abnormally low value for vouchers redeemed are flagged. VAMP also analyzes other indicators (the following definitions correspond with the alpha-numeric variables listed under the "vendor scores" field of Attachment VN-19):
VN -14

GA WIC PROCEDURES MANUAL FY '96

ABCDEFGHIJ KLMN-
o-
P .-
Q. -

Small Amt. of Price Variation Large percent of food instruments redeemed at same price High average price CI - Peer C2 - Flag Redeemed price higher than Vendor Price List Large percent of High-priced FI EI - Peer E2 - Flag E3 - Deviation WIC business High Volume Large increase in Volume over 6 months Vendor has large percent of total area redemption WIC Sales High percent of Total Vendor Sales WIC and Food Stamps High percent of Total Sales High WIC to Food Stamp Ratio Complaints from Clients, LA, Other Vendors Large percent of participants outside Vendor area Large number of clients at High Risk redeeming FI Large percent ofManual food instruments redeemed by Vendor Large percent offood instruments with consecutive serial #'s redeemed by vendor High percent offood instruments cashed same day

For each vendor these indicators are ranked monthly.using a scoring system. The scoring system used to identify "high-risk" vendors (i.e., vendors who may be violating WIC Program rules, regulations and procedures), is used as a guide for scheduling compliance buy investigations. The Vendor Profile Report (Attachment VN-19) summarizes the vendor's activity.

VN -15

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l

VENDOR APPLICAnON BOOKLET

WIe
Vendor Application Booklet
Georgia Department of Human Resources
FFY 1996

VN -16

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

Contents

IncroducDon

TIle AppliCluon Process

Vendor AppliCltion Deadlines

2

VIlC Minimum Inventory Requirements

2

VIlC Approved Foods List

3

Form 3770 (1) -AppliCluon for

Vendor Certification

5

Form 3770 (2)

6

Form 3771 (1) - Vendor Agreement

7

Fonn 3771 (2)

8

Form 3771 (3)

9

Rolling Store Addendum

10

Rolling Store Route Schedule

11

VIlC Vendor Agreement Between Military

Commissaries and Local Agencies

12

VN -17

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

Introduction

_

R etail food stores and pharmacies playa critical part in the WIC Program. As the actual distributors of the special WIC foods, the vendors are essential in their role to help improve the nutritional status of the members of their communltles.
The \VIC Program benefits the vendors who are

selected to participate-not only because of the direct contribution ofWIC food sales, but also because the 'VIC participants who go to an authorized vendor to obtain VVIC foods normally purchase other products at the same time. In rerum, vendors are expected to exhibit accountable behavior-both with the participant as well as with the VilC Program.

The Application Process

_

Step 1 - Completing the Application The retail store must contact the Local 'WIC
Agency in its area to obtain a vendor application. The score owner must complete the application
as shown below and return it to the Local WIC Agency.
Step 2 - Processing the Application After the LoCal VIlIC Agency receives the complet-
ed application, a pre-approval visit will be made to the store by the Local VIlIC agency's representative.
The following criteria must be met before a store can be approved for WIC participation.
1. Upon the sale of a WIC-authorized store and the purchase ofa previous WIC-authorized store, the new owner/vendor applicant shall prove that a legitimate bill of sale took place by complying with the Bulk Sale Law found in the Georgia Official Code Annotated and Unannotated.
2. Store must have the minimum inventory. All retail grocery stores are required to stock a minimum inventory ofWIC-approved foods. Outdated foods will not be counted in the minimum inventory figures. Stores will not be WIC authorized if they do not have the minimum inventory at the time of the pre-approval visit.
3. Shelf prices (on WIC-approved foods) of the vendor must be compatible with other stores within the state.
"Compatible" means prices must not be more than 10 percent above dle state average by peer group 1 store prices.
4. The store must be free from any current

Food Stamp Program Sanctions.
5. The store must be eligible for Food Stamp Program authorization.
6. The store appearance must be sanitary with no evidence of general lack of cleanliness.
The State W1C Office will work with the Georgia Department of Agriculture Sanitarians to determine the appropriateness of this criteria if it is used as a reason for disapproval of a vendor application.
7. The store must be open for business at least eight hours per day, six days per week.
8. WIC foods must be within current manufacturer's date limit for human consumption.
9. The vendor must be located within a reasonable distance of participants.
10. The Food and Consumer Services Office of the United States Department ofAgriculture reserves the right to approve any uses of the WIC acronym. The"\VIC" acronym and logo cannot be utiliz.ed by a store or on a vehicle with the exception ofdocuments distributed by the Georgia \VIC Program.
11. The rolling stores must meet the additional requirements below. However, continued authorization of rolling stores is currently under review. Therefore, all procedures and policies pertaining to rolling stores will be null and void if rolling stores are eliminated from WIC Program parricipation.
A. Each operating truck must be refrigerated and be licensed by the Georgia Department of Agriculture.

1

Vl'l' - 18

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

Georgia Department of Agriculture

#_------------

Truck Tag #

_

B. Submit a route schedule to the Local WIC Office at the time of application. An updated schedule must be submitted to the State and Local WIC Offices within thirty (30) days prior to implementation date. (Route Form attached).

C. Submit the location of food storage facility to the Local \-VIC Agency and the State WIC Office at the time of application.
D. Must notify the Local Agency and the State \VIC Office when new trucks are added.
E. Vendor will operate only in county(ies) served by the district in which he/she is applying for vendor certification.
(Continucd on page 4)

\VIC Vendor Application Process and Deadlines

1-Oi1lUJu........=.;::..:r.""'-+W-u....._ _-+-_....Ll.I-ll.lLl..I.I....LZ.2=:..:t;loIlJ..~a.....

July 1. 1996 - 4:00 p.m.

July 31,1996-4:00 p.m.

+-=a"c.1Jw.:'i':/S.L..::.:=J..p..m..

---l

August 15. 1996 - 4:00 p.m.

WIC Minimum Inventory Requirements
The following is. list of the minimum inventory requirements for WIC vendors which outline the required quantities. sizcs. types or br.nds. which the store must carry in order to become or rem.in 'vVIC \cndor.

Food Item

Quantity
I

I

Size

I Number of TypesIBrands

Milk: (~aseuerized) :

20

I

1 GaI.Jug

I

I Brand

Note:' Ou.ntitv rna\' include whole 2% I% and skim milk in the ""!lon size container onlv.

Cheese:

16

1 Lb. Pkg.

. 1 'lYres

Eggs: (Grade A Large)!

16

1 Doz. eggs per carcon

I

I Brand

Juice:

I
I

24

!

12

I

4<5 oz. can 12 Oz. frozen container

I
I

2 ~'Pes 2 ypes

Cereal:

30

9-200z. box

Note: At least two (2) cypes of cereal must be in 12 oz. size.

PeaslBeans:

!
!,

8

Peanut Butter:

!

8

lIb. pkg. 18 oz. iar

I

4 L:vpes

I

I

21)'Pcs

I,

2 Brands

Tuna:

8

Note: Must be oacked in waeer

6 oz. can

I

1 Brand

c."rrot~

4

I lh nL-".

i

I Brand

Formula: ( With Iron) :

186"

13 oz. can

I

1 Brand

Coneract brand of fonnula only. Vendor must be able to supply soy, powdered, re.dy-to-feed, concena.te, LaccoFree or a

different brand of fonnul. upon request.

Vendor must stock a minimum of 32 cans of Prosobee (soy base Contracted br.nd) fomlUla, 16 c.ns of LactoFree (lactose

reduced Concentrated brand) fomlul. and 138 cans of Enfamil (milk base Contr.cted brand) fonnula.

Note: Low iron fomlUla does DOC meec 'VIC minimum inventory requirements for formula.

Infant Cereal:

12

8 oz. box

Notc: At le:1SC onc (I) '!l'c of infant cereal must be rice.

1 Types

Ph2nn~cics2rc exempt from dIe Inininlunl inventory requirements, bue must 11lect the maxitnum pricing criteria.
--

2

VN - 19

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-I cont'd

VENDOR APPLICATION BOOKLET

WIC Approved Foods List

Food Item

Brand or Type

I ContainerlPkg Size CannotBuy

_J I Milk (pasteurized)

Whole, Skim, 99% Fat Free (I %l, or Low Fat (2%) O~ Gal. Size ONLY

(Least E>:pensi\'e Brand Only)

(Exception: 1/2 Gal. or Qrs.

of Enjoy, Laccaid, Acidolphilus,

Acidophilus, Enjoy, Laa:aid, Laa:aid 100"

Laccaid 100, Nutrish, and/or

Nutrish or Dairy Ease

Dairy Ease, 12- Oz. eons

Evaporated

I Evaporated,3 or 5Qt. Boxes

Powdered

Powdered)

I flavored Milk,
Buttermilk, or Goat's Milk
I.
i
!I

f----

-- ----------------- --------------'---------1

Cereal

Oleerios, Chcx (Com, RKc. 0< \\1"",<), Crispy Critters, Country Com Flakes, Kix,

Nine (9) Oz. Sizes and Above \' Eight (8) Oz. or .

ONLY

Less Size Boxes

Nabisco Quick Cream ofWheat (Rcgubr Fbvo<), Product 19,Jim Dandy QuickGrirs (\ron Fon;(ocd~

I Can purchase more dun one (1)

Minute 3 Brand Instant Oaoneal (Rcgubr F1a,,,,,).

cypeIl>rand ofcereal as long as the

I-hrv= Instant Oatmeal (Rcgubr FJa.....).

amount does not go over the

Quaker lnswtt Grirs or Oaanc:al (Regubr ~"bYor).

quantity on the tronc of the

Tocal-Com Flakes

voucher

Kelloggs - Special K. Com Flakes

AmenC:tn {S1iccd Of 8Ioc:I:), Cheddar (Block).
CoIby(ll\od:), Mon=Jack(ll\od:), Mozzarella (lilock),
Kraft Dcluxe(sIiced & singly wrapped)

Nine (9) Oz. Up to 16-0z. (One II] Pound) Size 01'.TLY

a.ecse Food,
Shredded or Deli
01eese, :tnd/or 2-8 Oz.Pkgs. {or 1
or 160z. Pkl1;. (no 8
Oz. Pkgs a.ecse)

Juia:(lOQ% USRDA
. \'iomin C Fortified)
Eggs
(Gr.odc: A urge O:'oo'LY)

Orange:l.cost~~B=dOnly
Grapefruit: l.cost ~ B=d Only Grape: \~~kh'SOfJuicyJuk<
Apple: FbYoritc:. Ludy La, Suff, Shur Fone:. Kroger, S<n= (Rc:d ubcl Onlj'),Thrift) M>id. Whit< Iiouso: Other: Oak Ot.nt;clPineaPl'1c:. OakOrang<!Pinea(l\1ldll=uu Ju~'Juk< Oteny,Juicylui Punc:h,JIricyJui<:< Tmp;ol
Least Expensive Brand Only

46-0z C:tns or 12 Oz. Cans Frozen ONLY
One (1) Dozen

Juice Drinks,
FreshSq~
Juiee, Single Srvng.
Sizes, InbntJuioes, Juices With Sugar Added
Any Other Size/Qnty.

Dried PeaslBeans

Any Brand Without flavoring Added

One (I) Pound Size ONLY

An}' Other Size/Qncy.

PeanutBu=

Any Brand WithoutJe11y Added or Honey Spread 18 OunceJarsONLY

Any Other Size/Qnty.

Infant Formula

As Listed on the Franc of the Voucher

As Listed on FrontofVoudler

Unlisted on VOucher

Infant Cereal
(Bo,;c:s Only)

Beech Nut, Gerber, Heinz

Dry Cereal in 8 Oz. Sizes ONLY Any Baby Food in
Jars or Any Dry

I Cereal Wlth Fruit or Formula Added

I--------+--.---------------J-------~I----_!

TIlIl3

Lc3st E.xpensive Brand/Water Packed ONLY

(; OunceCansOI\.'LY

I Tuna Packed in Oil

CarrotS

Fresh, Whole

One (1) Lb. Prescalcd Plastic BagOl\.TLY

Bulk, Frozen, C'Wlcd, $hredderl,
or B3byCarrots

3
VN -20

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

Vendor applications will be processed once a quarter. Applications must be received at the Local ""'IC Agency no later than 4:00 p.m., the first working day of each quarter - October, January, April and July. The Local WIC Agency will visit the store and complete the Vendor Review Form process. TIle Local WIC Agency must submit the entire vendor application and Vendor Review Form to the State WIC Office by the end of the first month of each quarter. The State 'v\TIC Office will approve or deny all vendor applications by the 15cll of the second mond) of each quarter. (See table on page 2.)
If a vendor application is approved, the State 'v\TIC Office will issue a vendor number and return the vendor stamp along with the carbon copies of the application to the Local WIC Agency. The agency will issue the stamp to the vendor and give the appropriate training..
If a vendor application is denied, the State WIC Office will write a letter to the store explaining the reason(s) for denial, 'The store can correct the reason(s) for denial and reapply for WIC program participation. Action will be taken on all vendor applications within forry-five (45) days from the first working day of eacll quarter.
SaIe!Purchase ofStore or Change of Ownership
Upon the sale ofa WIC-authorized store and the purchase ofa previous WIC-authorized store, the new owner/vendor applicant shall prove that a legitimate bill ofsale took place by complying with the Bulk Sale Law fOWld in the Georgia Official Code Annotated and Unannotated. In the case ofchange ofownership, the State WIC Office will review applications expeditiously to complete the review process prior to the forry-five day deadline.
ATTENTION-WIC vouchers must not be accepted by the applying vendor during the application processing time. This relates to all stores, including those that are changing ownership. If for any reason a store accepts vouchers and is not approved for ""'IC participation, the store will not be reimbursed for those vouchers.

Should there be a delay in processing the application and the new owner is in possession of stale dated vouchers, the store will not be reimbursed for those vouchers.
Step 3 - Training and Signing the Agreement
Once a store has been approved, the store will be trained by the Local WIC Agency and a ""'Ic vendor agreement will be signed by the store owner or Store manager prior to issuance of the vendor stamp and the acceptance of'v\TIC vouchers. A rolling store owner or manager must sign an addendum to the vendor agreement and the rolling store route schedule. A commissary representative must sign a military commissary agreement between the military commissary and the Local Agency. (See the following pages)
A WIC vendor is expected to comply with all requirements stated in the vendor agreement. A copy of this agreement, rolling store addendum, rolling store route schedule, and military commissary agreement are included on the following pages.
The vendor is expected to also comply with all policies and procedures as outlined in the vendor handbook. A copy of this handbook is included as a part of this information packet.
Any applying store or rolling store that is rejected for participation in the program has the right to a fair hearing. A hearing must be requested in writing and received in the State WIC Office within fifteen (15) days of receipt of the denial notification. The appeal should be submitted to the address below and not to the Local WIC Agency.
State WIC Office Two Peachtree St., N.'\., 8th Floor
Atlanta, Georgia 30303 (404) 657-2900 or WIC Hotline 1-800-228-9173
Any additional information regarding the WIC Program can be obtained from your Local WIC Office.
Thank you for your interest in the \li,'IC Program.

4
VN -21

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-I cont'd

VENDOR APPLICATION BOOKLET

;(Otc N.lmc ;{orc l.oc:uion '-13jfin~ Address (If Oi((CfCn() i(ore Owncr :.E.J. NtJmbcr

Georgia Dcp.1nmcnt o( l{um3n Resources
DrYISION OF PUllUC H8\LTIi
r-oR WOMEN. INFANTS AND CHILDREN
WICPROGRAM
APPLlCATroN FOR VENDOR CERTIFICATION

City

TcJcphonc Numhcr GJ'.

AraCode

(--...:, ---------

Zip Code

_

County

_

Store Man:lgt:r

or Ow'ncr's Soc. $cc. Number

'-

_

!Federal Employer Idenli/ier) fYPE OF STORE J Chain ) Independent ) Fr.lOehisc ) Drug \qu:lrc r-oot.3gc..o' Store _" \ven:gc Annu.:lI Gross S3k:S S tWd Sump Authoriz.:uion Numbcr

HOURS OF IlUSINESS

Sunday

Mond.y

_

Tucsd.y Thursd:!y Salut"day

Wedncsday

_

Ftid.y

_

_

Number of ChccL:-out Counters I::slim:ncd TOtal % of Food Sales

_

...;.l(';j.'-

'-

_

(A store must b'C ~Ii;ibl<: for Food. Stamp Program AuCltoriz:ation (0 be-:. \VIC Vendor.)

of Oc~nmcn( Agriculture License Numbc:r

_

(A store must be lICensed by lhe Depanment 01 Agriculture to be a WIC vendor)

Business License Number

Sales Tax Number

_

Length of time business has opa:ncd at the present site

_

Yes No
o o

00 you sell beer. wine. or other alcoholic beVCr:lges? Has the business eva operated under anolhcr name? If yes. wh:n was the 113m<=: of the business"?

:l o

Is this a ch3ngc of Ownership?

J

o

Docs this store now panici~tc in the Food St:llnp Program?

o

o

Ii,s this slore cvcr .pplicd (or WIC? If yes. slate when

,-

_

o

o

!i:ss this store ever received 3 warning. been suspended. disqualified. or had a pc:n.alty assessed against it b)'

\VIC or Food Stamps? If ycs. Slalc when 30d explain

STATE WlC OFFICE USE ONLY

Food Pkg. _ _ _ _ _ _ _ Vendor Cost

M ..

r-ood Pkg. _ _ _ _ _ _ _ _ Vendor COS(

Max

Food Pkg _ _ _ _ _ _ _ _ VcndO! COSt

Max

Arc ston: prices comf!'Ctiti,,<, with Other stores in Statc2....- _Ycs__ No

App'ic~(I(ln

Approv<J - - - - - O,J{C

Denied

Datc

Vendor Number Assigncd Processed by

Reason D.:nied

Price Ap!""ovcd Price Approved PriC1:: Approved

Ocnied

_

Denied

_

Denied

_

_ _
_

r.1l;< I 0(2

5

VN -22

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-I conttd

VENDOR APPLICATION BOOKLET

Store N.3m<:

Namcof bank whc.cc \VIC '\I()uchcrs win be:. deposited Daiey productS arc rccci\cd (rom

Otl"Cl \VIC prod.uclS arc received (rom

a 00 you own or manage .any ot!lc:r trocery slorc(s) I drug storc(s)?

Yes

(fycs.list name and addresses of store(s)

o No

_

_ _

,--

_

_

To the OcSl of my kno....lcd~c. 2:11 of the ;,hovc .ao'!. ....C('S .ate correct. I undCC'SI,;,and dl3t. should my stOIC he 3cpled .as ~ \!,,'le vendor. I wilt ;thi:& by \VIC p(O~(3m rc~uIJtjoos. and poll(",c~ includin~. bot ClO( limited to the (oU()winc;..:

t. Auend Vendor E.duc.3tion~ 2. Train c.mpl-oyec.s (cg~rdln~ \VIC PfOCCCU(CS~ 3. rcriod~c31 moni(orin~ .zn.d: 4. All i.ems in tI~ vendor .agrccmcnl.

I UNDERSTAND TIIATTIlIS IS ONLY A REQUEST FOR AI'?ROVAL AS A WIC VENDOR AND DOES ?'OT CONSTITUTE ArrROVAL TO rARHClrATE IN TIlE WIC rRO(;RAM. THEREFORE, I WILL NOT ACCEl'T AN" WIC VOUCHERS UNTIL SUCH NOTICE Or- APPROVAL liAS BEEN MADE,III..WEATTENOEO VENDOR TRAININC. ANO IllAVE BEEN ISSUED A W/CVENDORSTAMr.

Sj~n3tU(c..._ - - - - - - - - - - - - - - - - - - - - - - - - - - - - Ooale

Title

.

n\O'lO i'lO.an l:.qu31 Oproononil~' 1',o;r:aUl r<I"OM ...iao bclfc"'C dae~' ~."C t-c:o:n (Ii~nn,il'l::l'cd ~:lIift':(l I,".;lu<;c of (3<:'<:. coto(. u~o<NUl on:,n. ~". :lI~. ()t h.1l'doC.1fI ~ld ~c iJ..",c:&~dy 10 $cernJ')" of A;n:uhllf<. W4Qu~. 1) C 20250

"ES NO
oG

FOR LOCAl. USE ONU'

COllllUCltl"':

_

oa

Conuuent'!i.:

_

1ccnify that t ~v<:: \isilcd this Slor~ aud do I do not tecommend its approYal (or p3t\icipation. I( this applic3tion is nOt recommended (or

approval. ptC3SC aptain why:

_

l)lSTRICT UNIT

LOCAL AGENCY \\"Ie COORDINATOR OR OESIGNEE

6
VN -23

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-I cont'd

VENDOR APPLICATION BOOKLET

__
~~.,.e...-...
O - ' - .......oMe _ _

- = - ."-0 ~S~QAl,.. SU'f'Pt...CW(N"D.l. 1"000 ~ M

wo",c"C .......",n .. OOC~~l

VENDOR AGREEMENT

Paqe 1 of 3

This vendot/~ AQreement is made by and between t"e ~ Oeoat1ment (l( Human Rescun:.cs., O'vision 0( PubIC Health. ~atlh OCslric;:t

_ _ _ Uni<

.(he~naftCf teferre<l to as the Loc:aC I<Qency1 end

_

(hetetnaf1et teferred to as ~ VendOt1 to ~ fneChanGm Cor the CSistrt:Ju(en (l( CQeC:W ~ toods So eCOb'e WIC oal1ic::ioants in the

<:ounty(tes) induded in thCs Heanh Ois(,id .Jurisdictton. This agreeme~ wta become: cect.iYc on

_

and wiCl terminate on

_

WIC VENDOR NUMSeR

The ut'dec"signed reorescnfs {he Vendot as the SOle Qn)Orietor Of" the st<xe The uncSetsigned ~ the locaf NJeN:;y en::5 has the authotity Co cnanaoer to contrad 'or and' on behalf of the Vendor idenC:ifted bebK. contrad. for and on bet\aft' at saC:S agency. (Signature MUST be of ~ or stOte mat\ClQeC'.)

- -.....

- -.....

PURPOSE:

.............

_;on ..... This

Agceem01en_ ! is f_ or the:foIo)UdIl)iOnsSI<euomfeo<cllo$Ytidoirngthae

mec::hanism foe' ouo'dlase CII ""

the ,fo

odCdstirliebmtulsi.::lTnhce(

oec1atn
Vendor

iWs _ed

foodsSOtolel~ y tor thpear_tCOanlS

saent

d f

the orth

~ and ShaG not be c:onsideted as an emobvee OJ( ~ of the Deoarttnent.

lliE VENDOR HANOBooK IS AN AOOENOUM TO THIS AGREEMENT.

e- ..,.
""""'ss
_.-
""'"""ss

7
VN -24

GA WIC PROCEDURES MANUAL FY 196

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

P.~2of3

THE RETA.LL VENDOR HERESY AGREES ANO COVENANTS AS FOLLOWS: A. 1'0 dock an &deQuaH!: $l..COIy of aultw::trized types and bC"eC'ds 01 wtC Program lOo<Ss.. 1n .a cateQOC'ie;s. as detetmined Oy the Geotgi.a WJC
Pn:>Q<am. e. That alt crioes wit be cieatfy mat1ct:d ~dheC on the tood "em oc prominently <l~_ C To post the . ~ W1C ~ Foods Lest in. conspC:::uous pt2ce by all cash teQistcrs.
o 10 ee.ceoc: we ~ tot' payment 0( the s:>urchase eM only e'Qible W1e ioods (see ~ FOOdS l.est) In .add4ior'1. ttoe -..en:SOr mvst
.accep( all vahd VIC ~ . To ecceot ro wtC ~ as oaytnent on past Of( present credit account(sl. To acceoC no W\C '<IOUC~ lrom panteioants presented after thitly (30) days trom t~ Issuance date OC' COOt 10 6sut; <l~te shOw'n on the

..ouc:r~.
G To acc.eot t.XIt'/ ~ whi:::h contain a Geof9i:a Y(tC Program SEAL

H. 10 tefuse .coeotanoe oC art( food instrument on wt\iCh arrt atlefations have been made.

once. I. 'To cd WIC Cood i&ecns .at OC' bdow the n::M'1\'\aI sb'e Chef(

but not to exceed the tnaxtmum amount lCsted on Che ~.

J 'b Defmit 'NtC pn)QC'atl\ patticipants 10 ~ efiQib'e: (ood ~ wiCMuC making CCheC' ~s and SO aeeon:l 5ud'l t)al1ieioants the
~ c:ourte:sy oM:n to (l(hec' coce ~

K. 10 Ioeeo a I _ c o a t _ o n W1C oart~.

L To diteet queSCoions concerning paycneot. ~ OQeC'ations. etc.. 10 the Local Aqertc(;. pa~ _ not be c:ontaded ~ning these

t'X other problem a.oeas.(Food ~ st\aIC not seek n=st4t~ fcom partic:Oants (0( ~ no( paid by the $ta1e.'

.... 10 _ _ INl no esd\Inge (l/ money t>etween the ~ and ~ laloes plae<o <lo<inQ a W1C ~ I<ansa;,n.

N. 1'0 albw no r.sinc:hed::s CK o:c:hanges 0( *"y ~ tor c:a:stt.. credit. CQOOnS. stamos. ~ oc ~ foc>d.s: ~ Vendor is

not ~ hom QivinQ or ~ eouoons. stamps. Of ~ ~ ~ s as il oucd'\ased ~ cash.

we O. 10 - . . . at the I"" (l/ (lUf<:hase an """"'"' eustome< ............. on ....

-..:he< ond .eQUeSl .... . . , , _ to " ' - woe identification

we we eatd bef~ the ~ 0(

toods can be <::omC)Ieted. the customee' is c..nab'e to 5hOw &

Oen.~Gation e;at(S bearing the s.ame

.......- as ~ on .... """"'"'". the _

should "'" _

the WIC"""",,"," as_men< tor .... food(.t

P. O.

To 10

insert. i'\ i*., the actIsaI costcC' he WIC Ioods.on _ _ alI.cuc:hecs ..... lhe authorized

the

we ~
(~

(ace at by the

the tme I.ocaI N

do pI

C)C,Itd\a:Se in cy! b<:Io<e

_the"~ ' 0 ...d.o.

.thbeanciu<st.o.m.,etro.

_

..

'""""'= .. W1C

a l""ely _ . ""*'>Ib/y within 1~1eet\ (t51 dayS (l/ _ ; , n bul not ..,... "'"" Ox.. (SOl dayS ""'" .... dale 01

Gsuance ct"owf\ on the 'IIOUChec' lace.



cI ~ 1. The owner OC' manager ~ is legally ~ 'lot the .Aofto must sign the Vendor ~ IIA:S snal auend, teguIattf SCheduiecI

(~ hnng _

tor W1C Iiend<l<'5. wl\"", lhe _

wit be notil;ed by .... local "-<:t. The ......... 0< _ _ attenc:;ng

8t'lf ttarning cessOn(s) wil ~ the in(oCmatloR ~ as ttainCng material k)( all thek' ~ wh:) at': n..oNe<S i'\ WI<: Program

2.
3.

oAar.t.C..i_oat",,-

Cu"oIdiIuodrm"'o

l.'.o.5.le.Thee5ctt<o.u..t

.d.e

<b\e<

$

.
~

to

e.

'

, ......... duMQ _ _ to ~. ......... ~ ~ and

cI ~ set by the Stale WIC

"lhe<eI..... eaen _ _ manage</_ _ ...... o<:on: ~ " - y (701

cI ........ 0< t,;gt...- on .... l'o5l-Tesl. The _ _ manaoe<l<,....... who SCOte$ below .... desWed ~ _

(701 _ _

10< addiGonalltainrog. in del""",, atea5. wah .... local WIC AQency ~t"".

To diolribu\e to all ~ _ _ in the _ s woe Pn:>Q<am _ - " 0 0 aI con,,",""'''O',. . . - _ the Loc:al AQency

_'s __'" _s pettinent to the

the W1C Pn:>Q<am. To .......ue:t .,......... and aI clhe<

in the

WIC

P<og<am partic:ipalion (l/ the el9ble lood5 ond .... co=ct ~ 01 W1C~.

S 1

4. The _

d b e _ for _

cI_inthe<lliiUGonol ~O<...,.;sioncl_ loods.

cI _os _ . 10 - . by <uIeS and 1'tguIa(;ons Fedem. Stale and local AgenQes aC1d aI """",<lutes as oc.<1ined in ....

tef..- 1. That lhe Stale _

nIOy deny ............ to .... Food _

to< """"""" food -.c:l>e<s 0< may demaC1d

to< _ _

U V.

aln>adv made on inoo<ooec tood """""""'.

2. To..,;mtlu<se .... Stale AQency within IlWly (30) days cI _ICation for amounts "'0 by the State "-<:t on W1C Prov<- toed

.ouc:henl_by the_

wNclIa", .-. lhe _

..... price clloods.

=-se. . ::..~.. '=:::-""'::"cI":=~~~:~~:,:::::

='";,:~~ lhe

That

..., the ...,.,.ny 01 the Stale eli Geotg;a and thai sal _

d be n:tumed '" the W1C Prov<am _ l e I y . - .

_from _ _y leM1d1alionI~di5qualil"c&l"",

lll"OllI'Ot" paltCipal;,n.

VI t. That the _ _ 0< the _ . _ ~ . ) not _

we ....-... 0< _

W1C lood ie<ns. esoeciaIY"'" lom>ub..

when W1C

used 10< the ou:hase .......:

a. Notified in writing by a heatlh department ~tiYe.

b. The

is e"""""ll;ng. VJ!C _ _., due-to inaoc>cO",",teIy se<IinO ""'"",-dale W1C foods.

2. That an( out~<Sate Ioods wit be ~ from ~ and reolaced wtth ioods that have e~ton dates whic:h dO no. ~ the

_cl_maI~edusage. X. That 8"'J Vendor disQualified trom another FNS Ptogram st\aa. be d~lifted from oartic:iPation in the W1C ~ Cot the same pec-iod of

time. uo to ",fee (3) years. Y. "VendoC'" wtlo <::ommits fraud or abuse of the pcogram is Iiabfe to prosecut1on under aQC)Iic;abIe fe<5ec'al. sQte or bCal lawS. Those whO
nave wilfully misaDQIied. sto&en.. Of ftaudulentty otUined we fu~ shall be ~ to a ftne ct C"CIC ~ than $ 10.0(X). or 4mptisonmen1

lot not ~ tnan fcve (5) years. or both.

:.'" To notify the Locat NJte;y r::J. e:t\anOes in manaoernent or when the Vendor ceases ooeration or (:Hrfnershio Changes. TfWs Agreement is nud

and ~ if ownershiQ c:hat'Qe's.
AS. State of Geofoia or Local Sak:s TaJ:es wdl not be coaected on tOOd items pufChaSed w~(h we '\/OUChet'S.
~c 10 dedare It\at neitt\ef the vendor/owner. the vendors mat\3gef{s1. or the ~ndor's other emp&oyee(S) is ~ted by bbod 0: fftat'riage to

any wtC reoresent.atNe. unlessothef"wiSe revea4ed in writ'ng. upon cJ:ecu1ion. of the contt'3et/aoreemenl or within the conh'ad oef'iod. (soac:e

DI"OVidei:l on oa~ tht'ee of this contf~ 3g(CCfT\Cl"11 foe dCsc1oSUt'e 0( retatNoes).

"'-0 To visitMy disolay the venoors st()(e nar:w: on the outside of the stOle butldingftaci(ity "'-E to abtde by the U.S. PateN. and TraC!ema(1( \'2\'.1$. ~ orohCbits unauthOc'i.z.ed use 01 the WIC 3CTl)nyfT\ and 1090 (telef Ie ReQistr3tfon
Numoct' 1.630.468.OC()\{ideCI in 42U.S.C. l876. i5 US.C. lO:'i et. &e<I. ...... :17 ~ ?~r: 2G61.

8
VN -25

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-I cont'd

VENDOR APPLICATION BOOKLET

WIC VENOOR NUMBER

Pag-e30f3

Office adCre:>s 01 t~tT...e U\al r'epn:sents the GeOC'0'3 Wi<: PrOQfam ()( en'l()Ioyoed by the GeorQia WIC Ptogram

Phone Nu_<eft;:"l, <_ _~L

-,-

_

(Aease attach 8ddit'onaJ oaoe<s) if neoesUly)

11. THE LOCAL AGENCY H.ERESY AGREES ANO COVENANlS AS FOLLOWS:

A. 'TotnsttUC1 the VendOr UOOtlet'\try into the ()fOgC"lmof the aQOtOOriate Pft)Cedures 10 ptOCess WIC~. B. To pl'tNiOe ~ Vendor with the 0Jf"I'ef'lt 'ist 01 foods ~ tot' dCsbr"r.r.ement to v.nc Ptogtam QaI1icipants and to Cs$ue L()dates to t~

food List as they oc:c:......

C. To orovide edueattonal cnater'al abOut the VIC Program to the Vef'IdOt.

O. To tnstC'UCI '11fC participants and DtOX~S in ()tOOeC" use c( WI(; VOl..IChefs.

e. To ensut'e that an .authotlzed oartieiQant or CMOxy signature G affixed to any manual ~ Qrioc' to tdeaSC'lg the vouc::het 10r f'edemoton.

F. To notify the VeftCSOc' with a COPY of at't'f d\angeS in YOuC:hets or l4e oi \IOUChetS and anr chaf'QeS in the FedetaI and State Reoutations

that may afled the Vencjor. and to ~ the Vendor with a eopy of &"f wtC regulatCn(sl or pOlicy ssuance(sl affedtng the Vendor"s

oartieOation ... the viC Program.

we G. To assis1 tI'w! Vendor Mth atty l'f'()C)Iem teiat""; 10 the

Prooram.

H To provide the Venjor with a unfQuety numbel'ed &tamo.

IlL eon< PARnES "CREE AND COVENANT AS FOl1.OWS:

A. That no conUet of intete'$t exists between tne Vendor and the l.ocaI Agency (See Section I~ AC.).
8. Not to disO'iminate tor teasOftS 01 age. f'aCf:. COlor. sex. nationat origin Of handeao. C. The VendOr has the right to ~ any decision made by the Locaf /Iqe:y affecting ttle Vendor"s ability ~ partciPate in the WtC Prooram

o
E.
F. G.

_;on '" _os Jt'de< the ~msd this Agreement

The oet'Od or thi:s ~ is set forth on the signatute page. New ~ MI be exeo"ted each year.

This Ag~ Shall become null and vo<l in its entirety uooa any cNngeS 0( ownef:ShiQ of Retailer.

seale " - This ~ may be canceled bv"- oatly wihltWly (301 da';s writ"';-.

.. .......... '"

funds bv .... lunditlg _ _ to !he

10< the WIC Prog<am. this ~

Onmediately.

H. That nef:her !he 1..OCaI Agen::y nor the Vendot have an ob&igaIton to ~ the Vendor ~ . "I This ~/conIraet does not COttStitute Iic::ense 0' CMOPerty iMec'est. The ~4onshio between the Local Iqent::v '"and the Vendor

ends witta the exoiration dale of ttks ~/contracl

1\. SANCOONS "NO APPEAL PROCEDURES:

A SANCTlOt<S

wee ~ Shall 1;)e ClisQualdieci trom

ProgQft\ particiPation for a perOd of 4.0 to three (3) )'eal'S if violations occ:ur during a c:omo&&arce

QurcNse. monitoring visit by a VJIC, reoresentatM!.- 0'" Food Statno Prootatn QattCOation. ~s for inQ)sing the sanctions a~ OUIstneCI

in the Aetac \tendo( Hand()()ok. Any vendOr disQuafdied fC'tlC'ft wtC parteoatiotl may be disQualified &om Food Stamp Program partieipation.

Rete< to 7 em 278.

e APPEAL P;:;;OCEOURE

Vef\dOrs ar~ entitleCl to a tarr he3nng ~ CllsQualiiation ttOm the WC Pl'OOram. Any ~r feQuest.g a (air neal'"ing must. contact the

wac Local 1..Qerv:::., by le;eohOne. and conLaa the State

OUce in Wl'"itmg within (tlteen ('51 days aiter the achon whM:h is being taken

v. TERMINATION POUCIES:

A A V-enoor $r.att ~ \erminaled from vile Pro9ram oarticiPatOn i( the stote is NOT licensed by the Geol"Q~ Qeoaoment of Aoreut1ure. 6 ... ~.xivt s.;~::.c :~r:;.; . .:.~~ t~ WI<: ~ta", 93r1icioaten if the store~not e19'* for Food Sta~ Program part<:ioation/ au1hOtiutton
or a VeM:-t IS w(hdtl!WQ {fern FoOC! Star."O Program parti0c3tion.

Form 377' (F:\c~'" 6951

!;.outin9: l~"hite Slate WIC Office. Yell()4Af - Local .c.9.e4"lCY. Pink. Vem:!or

9

VN -26

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

Georgia Deparunent of Human Resources Division of Public Health
WIC Program *Vendor Agreement Rolling Store Addendum

Contract year

to

_

Rolling Stores participating in the WIC program must meet the following requirements:

1. Each operating truck must be refrigerated and must be licensed by the Department of Agriculture

GA Department of Agriculture #

Truck Tag #

_

2. Submit a route schedule to the State WIC Office at the time of application. An updated schedule must be submitted within 30 days pnor to implementation date of changes. (Route Schedule attached)

3. Submit the location of the food storage facility to the Local \.\I1C Office and the State VillC Office at the time of application.

4. Must notify the Local Agency and the State VillC Office when new trucks are added to the fleet.

5. Vendor will operate only in coumy(ies) served by the district in which he/she is applying for vendor certification.

6. Vendor must visibly display the name of the rolling store on the outside of aU trucks operating to accept VillC vouchers.

Vendor Name (Print)

DistrictlUnit

Vendor #

Signature of Owner or Manager

Signature of Local Agency Authorized Representative

Print Name of Owner/Manager

Print Name of Local Agency Representati\-e

Date

Date

'Continued audlOrization of Rolling Stores is currently under review. Therefore, this Vendor Agreement Rolling Store Addendum is null and void if Rolling Stores are eliminated from \VIC Program participation_

10

VN -27

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

'. . Georgia Deparnnenc of Human Resources
State WlC Office
*ROLLING STORE ROUTE SCHEDULE

Vendor name:

_ City

_

County

Street Location

Dc:livery Day I Time Begin Time End -I Tag Number

I

I

I

I

i

I

I

I

I

,I
I

i

I

I

I

I

I

I
!

Continued authorization of Rolling Stores is currently under review. Therefore, this Rolling Store Route Schedule is null and void if RoHing Stores are eliminated from WIC Program participation.
11
VN -28

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-I cont'd

VENDOR APPLICATION BOOKLET

'WIe Vendor Agreement
Between Military Commissaries and Local Agencies for The Special Supplemental Food Program For Women, Infants, and Children (\VIC)

T he purpose of this WIC vendor agreement is to outline the basic responsibilities of WIC locI! agencies and military commissaries which have been autllOrized to be "VIC food vcndors.
1. In order to be an authorized \VIC food vcndor, tile commissary shall fulfill State criteria for authorization and shall sign an agreement witll tile Local Agency.
2. The Local WIC Agency shall agree that commissaries shall be reimbu~ed for the provision of authorized supplemental foods to participants, based on the standard commissary price system of procurement costs plus a percentage surcharge. The Local Agency shall furtller agree that co~missariesare only obliged to serve active or retired military personnel and tl1eir dependents_
3. The Local Agency shall provide the commissary witll a list of approved WIC supplemental foods. The Local Agency may not direct the commissary to carry a specific brand of merchandise, if that product does not fall within the items authorized for sale in commissaries or if the commissary carries an equivalent product from the approved list ofWIC foods.
4. The commissary shall comply witl1 applicable Federal regulations and Local Agency guidelines for WIC food vendors; such as: provision of supplemental foods to participants, completion and submission of food instruments (also called WIC vouchers), acceptance ofWIC vendor training within funding/personnel constraints,

and other Local Agency guidelines agreed to by the appropriate commissary headquarters except those excluded in item five (5) below. The commissary shall not discriminate on the basis of race, color, national origin, sex, age, or handicap.
5. In vicw of Fedcral immunity from Sene claims or review, the Local Agency may not conduct on-site monitoring reviews of commissaries (except upon invitation by the constituted military authority) nor require claims to be paid. However, the State Agency may review redeemed food instruments prior to payment. If the food instruments are found to contain errors or omissions, payment may be denied unless or until further justifiCation Or correction is provided by the submitting commissary.
6. If the State Agency wishes to further pursue problem resolution, it shall refer the case to the Food and Nutrition Service (FNS), U.S. Department of Agriculture. FNS, in conjunction with tile Department of Defense, may conduct on-site monitoring reviews and submit claims to commissaries for the VVIC Program.
7. Local Agencies are authorized to use the general guidelines above in writing agreements with commissaries, based on Section 240.10 (f) of WIC Regulations. Authority: Section 17 of the Child Nutrition Act of 1966, as amended (42 U.S.c. 1786): WIC Program Regulations (7CFR Pan 240).

Vendor Name (Prim) Signature of Authorized Military Personnel Date Signed

DistrietlUnit

Vendor #

Signature of Local Agency Represent:love.

12

VN -29

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l cont'd

VENDOR APPLICATION BOOKLET

IIill;),;~ t~
DHR GEORGIA OEPARTMENT OF HUMAN RESOURCES
State WIC Program Office Two Peachtree Street, N.W, 8th Floor
Aclanta,~or~a30303
1-800-228-9173
Standards for participation in the Ville program are the same for everyone regardless of race, color, national origin, age, sex and handicap..
Form No. 3746 (Revised 7/95)
VN -30

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-2

APPLICATION FOR VENDOR CERTIFICATION

Georgia Department of Human Resources DlVlSlON OF PUBUC HEALTH
.-oR WOMEN, INFANTS AND CHILDREN
WICPROGRAM APPLICATION FOR VENDOR CERTIFICATION

Store Name - - - - Store Location Mailing Addrcss (If Diffcrellt}

Arcauxk

Tekphone Number

<---l

_

City

GA Zip Code

_

-'-

CouOly

_

SlO(COw~r

St()(C M.anagcf

_

EE.1. Number

or Owner's Soc. Sec. Number

-'-

_

(Federal Employer Identifier)

TYPE OF STORE
o Independent o Franchise o Drug

HOURS OF nUSINESS Sunday Tuesd3y
111Ursday Saturday

Monday

_

Wednesday

_

Friday -c---------
_

Square: Footage of Sto~e

Number of Chec1<-out Counters

_

Average Annual yross Sales S Food Stamp Authoriution Numbcr

Estimated TOlal % of Food Sales

---=q;:lO"-'-

_

_

(A store must be eligible for Food Stamp Program Authorization to be a WIC Vendor.)

Department of Agriculture License Number

_

(A store must be licensed by the Department of Agriculture to be a WIC vendor)

Business LicCllse Number

Sales Tax Number

_

Length of lime business h,. operated at Iil<: present site

_

Yes No
oo oo

00 you sell beer. wine. or other alcoholic beverages? HllS the business ever operated' under another name? If yes. what WllS til<: name of til<: business?

o

o

Is this a change of ownership?

o

o

Docs this store now panicip:lte in the Food Stamp Program?

o

o

Has this store ever applied for WIC? If yes. state when

_

o

o

Has this Store ever rccei"ed a warning. been suspended. disqualified. Of had a penally assessed against it by

\VIC or Food Stamps? Ii yes. state wil<:n and explain

Food Pkg, #

Vendor COSt

STATE \VIC OFFICE USE ONLY Max

Price Approved

Denied

_

Food Pkg. II

Vendor Cost

Max

Food Pkg, #

Vendor COSt

Max

Arc store prices cotnp<:titlvc with other stores in St3(~

_Ycs __ No

Application: App<oved

_

o.~nc

Vendor Numher Assigncd

Denied

_ Date

Processed by

Reason Denied

Price Approved Price Approved

Denied

_

Denied

_

_

_

--'-

_

VN - 31

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-2 cont'd

APPLICATION FOR VENDOR CERTIFICATION

Store Name Name of bank where WIC vouchers will be deposited Dairy products are received froffi Other WIC products are received from
Do you own or manage any other grocery store(s) I drug storc(s)? Q Yes If yes. list name and addresses ofstore(s)

---' Q No

--=.

_

_ _
_

_

To the best of my knowledge. all of the above answers are correct. I understand that, should my store be accepted as a \VIC vendor. I will abide by WIC program regulations and policies including. but not limited to the following:

1. Auend Vendor Education: 2. Train employees regarding WIC procedures; 3. Periodical monitoring and; 4. All items in the vendor agreement.

I UNDERSTAND THAT THIS IS ONLY A REQUEST FOR APPROVAL AS A WIC VENDOR AND DOES NOT CONSTITUTE APPROVAL TO PARTICIPATE IN THE WIC PROGRAM. THEREFORE, I WILL NOTACCEPT ANY WIC VOUCHERS UNTIL SUCH NOTICE OF APPROVAL HAS BEEN MADE, I HAVE ATTENDED VENDOR TRAINING, Ar:ID I HAVE BEEN ISSUED A WICVENDOR STAMP.

Signature

Date

_

TItle

_

~

This is all Equol Opportunity Program. PetSOllS who belieYe they """" been discriminated against because of cac:c. color. nation.al origin. sex. age. or handicap should
wrilc immcdialdy to Seaowy of AgricultlUl:. WashingtOn. D.C. 202SO.

YES NO

FOR LOCAL USE ONLY

Q

Q

Is the state required minimum inventory of \VIC approved foods in the store during the Pre-Approval visit?

COmments:

_

Q

Q

Have you provided the vendor with the Georgia \VIC Application Packet?

Comments:

_

I ecnify that I have visited this store and do I do not recommend its approval for participation. If this application is not recommended for

approval. please explain why:

_

DIS1RICT UNIT

LOCAL AGENCY WIC COORDINATOR OR DESIGNEE

form 377Q (RC'. 695)

VN -32

DATE
la~c 2 <t( 2

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-3

VENDOR INPUTIREGISTRATION DOCUMENT

STATUS -ADO - UPDATE - TERMINATE -REINSTATE

TERMINATION CODE 1 - VOLUNTARY Wl1HDRAWAL 2 - SALE OF BUSINESS 3 - TERMINATION 4 - DlsaUALlACATION

MAIL TO: VIKING COMPUTING, INC. GA WIC UNIT P_O. BOX 2504 GREENWOOD. IN 461422504

GEORGIA DEPARTMENT OF HUMAN RESOURCES WlC PROGRAM
VENDOR REGISTRATION

PLEASE PRINT DATE. ORIGINAL W/>S PREPARED _ _'_ _' _ _

TATUS

VENDORID.

VENDOR NAME

U l--L-....L-...l.---.ll 1'--

VENDOR REPRESENTAnVE NAME
_

DATE PREPARED _ _'_ _'_ _

"NDOR TYPE STREET ADDRESS

uNO USE ONLY) 1..------------1

DISTJUNIT COUNTY

n:i..EPHONE

APPROVAL DATE

I I I I I I I 1-.1.1-1..I..-1...!-1-1.-1.-1..-L--L.....JL.-L- I 1 I 1 I I (AREACOOE)

CITY
\.
TERM DATE
1111111

TERM CODE
U

STATE

ZlPCODE

I~ LllliHlilJ

REINSTATE DAn:

STAMPS ISSUED

1111111

LJ

lTATUS VENDOR 10.

VENDOR NAME

U LLLLJ 1

VENDOR REPRESENTAnVE NAME
_

DATE PREPARED _ _'_ _'_ _

'ENDOR TYPE STREET ADDRESS WOUSEONLY)

UI

DISTJUNIT COUNTY

TELEPHONE

LilLLLI l.illlll.LuJ

(AREACOOE)

CITY

I ''--

APPROVAL DATE

TERM DAn:

~ wuu

TERM CODE
U

STAn:

ZIPCODE

Il4J UilllllJJJ

REINSTATE DAn:

STAMPS RETURNED:

WllJJ YES

NA

NO

HOW MANY?

STATUS VENDOR 10'

VENDOR NAME

U LLLLJ 1<--

VENDOR REPRESENTAnVE NAME
1 1<--

DATE PREPARED _ _'_ _' _ _
_

IENDOR TYPE STREET ADDRESS )WO USE ONLY)
u1

CITY
---_-..:. '--

STAn:

ZIPCODE

--'I~ UilllllJJJ

DISTJUNIT COUNTY

TELEPHONE

APPROVAL DAn:

n:RM DAn:

n:RM CODE REINSTATE DATE

UlWJ L1..LllLLuJJ lLLLW LLWJJ U LLWJJ

(AREA CODE)

STAMPS RETURNED:

YES

NA

NO

HOW MANY?

ONE FORM PER VENDOR

\TN - 33

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-4

VENDOR AGREEMENT
V<IC_ ~ ~..OCf:4uman~ DMr.ioo,iJ! {"Ub'ic:~
(SPECUL SUPPLEMEHUL FOOOPROGAAM FOR WOMEN" tHFIr.H'TS I. (;:Htt.J)fE~)
VENDOR AGREEMENT

P;Ige 1 013

This Venclo<IProvide< Agreement is made by and between the Georgia Department 01 Human Resources, DMsion d Public Heal\tl, Health Oislricl

_ _ _ Unit

(hereinatle< referred to as the Local Agency) and.

_

distribution (hereinafter referred to as the Venclo<) to ptOIIide a mec:hat1ism for the

d special so.c;>pleme<lta foods to el4gible WIC par1icipants in the

oounty(ies) included in this Health Oislricl Jurisdiction. This agreement wiG become eftectille on

_

and wiU le<minate on

_

WIC VENDOR HUMBER

The undersigned represents the Venclo< as the sole proprietor or the store The unde<signed represents the Local Agency and has the authority to manage< to contracl for and on behalf d the Vendor identified below. contracl for and on behalf d said agency. (Signature MUST be d owner or store managec.)

Si;natu<e"'SIo<eOwne<",_

0...

(l'rint1 ....... "'SIo<eO"- ... _ _

........ _<SIo!I

Si;natu<e"'t..o<oI_........-_
_dl.ocol_ tPrint, ...... "'t..o<oI_........-_

City
City
PURPOSE:

. -. IrrAai&ing Address ~ PD. Box
SIred l.oca1ion 0( ~ - SJ~ Adi:ke:ss
---Stale -- ....... "'SIo<eO"-(. _ _ _,
Stale

zc,ezc,Code

_ _ _PO.eo.

OCr

- -Stale

zc,e-

_ , , ' " Food Solos
- - - - -_..so-

----
-Securtly- - - ."Cosh~
'"

This Agreement is for the purpose eX proyiding a mechanism for the distriblulion d certain listed foods to eligible par1icipants and the

~ion eX negotiable food instruments for the IlU'dlase eX said food items. The Venclo< is Ielained solely for the pll(l)OSe set forth

herein and shalt not be considered as an ~ or agent of the Oepartmenl

ll-IE VENDOR HANDBOOK IS AN ADDENDUM TO ll-IIS AGREEMENT.

Form 3771 (Rev. 6-95)

Routing: VJ'~ite State WIC Office. Yellow - Local Agency, Pink. - Vendor
VN-34

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-4 cont'd

VENDOR AGREEMENT
WIG vENeoR NUMBER

Page 2 of 3

THE RETAIL VENDOR HEREBY AGREES AND COVENANTS AS FOlLOWS:

A. To stocl< an adequate supply 0( authorized types and b<aods of WIG Program loods, in all catego<ies. as <leIermined by the Geo<gia WIG

Program.

B. That all prices will be dearly mar1<ed eitt1er on the food item or prominently disPlayed.

G. To pOst the acceptable W1C Approved Foods List in a conspicuous place by all cash registers.

O. To accept W1C vouche<s for payment 0( the purchase of only eligible WIG toods (see Aoproved Foods LISt). In addit;on. the vendor must

accept all valid WI(; vouche<s.

E. To accept no WlC vouche<s as payment on past or present Cfedit account(s}.

F. To accept no W1C vouche<s from participants presented after thirty (30) days Irom lhe ISsuance date or proOf to ISsue date shown on the

vouche<.

G, To accepl only vouche<s which contain a Ge<xgia WIG Program SEAL

H, To tefuse acceplance of arrt food instrument on whictl ant alterations have been made.

t. To sell W1C food items at or below the normal store shelf price, but not to exceed the maximum amount listed on the vouche<.

J. To permit WlC program participants to pun:hase eligible food items without making other purchases and to accord such participants the

same courtesy gO.Ien to other store customers.

K, To keep all information conftdential on W1C participants.

L To direct QUeStions conceming payment, program operations, etc.. to the Local Agency; participants will no! be contacted conce<ning these

or other problem areas. (Food .enders shaU not seek festitution from participants for vouchet's not paid by the State.)

M. To ensure that no exchange of money between the store and participant takes place during a WIC \IOUCher transaction.

N. To allow no rainchecks or exchanges 0( arrt IIOUCher for cash. a'edit, coupons. stamps. premiums. or nonIisted foods; however. a Vendor is

not preclujed from giving or accepting coupons, stamps. Of premiums with purchases as if IlUfd>ased with cash.

O. To obtain at the time 0( purchase an original customer signature on the WIG IIOUCher and request the participant to show a W1C identification

card before the purchase 0( WIG foods can be completed. If the customer is unable to show a WIG gen\ification card bearing the same

signature as signed on the vouche<. \he Vendor sI10uId not accepIthe WIG voucher as payment for the (ood(sl.
P. To insert. in it'lk. the actual cost of the WIG foods on the WIG IIOUCher face at the time of purchase in the presence of the customer.

O. To ~ alt vouche<s with the authorized IIelldor stan:1p (provided by the I..J:JcaJ Agency) before depositing in the bank and to deposit all
WlC vouche<s in a timely manner. preferably within fifteen (15) days of redemption but not more than sixty (oot days from the date of

issuance shown on the vouche< face.

.'

R 1. The owner or manager who is legally responsible for the store must sign the Vendor Agreement and shall attend aU regularty scheduled

(requifed)Ir2ining.sessions for W1C Veodols, 0( whictlthe Vendor wiU be notified by the Local Aqerv::f. The owner Of manager attending

arry training session(s) wit! provide \he information received as training material for all \heir ~ who are im.<JloIed in WIG Program

participation, incIucfmg the checkouI cIerI<s.

2. A statewide uniform Post-Test shall be gillen to eacI1 "I!l'ldor manager/owner du&.1g -.dor training. to evaluate if objectil.es and guidelines set by \he Stale WIG /v;Je::y were achieved. Therefore. eacI1 wndor manager/owner must score a grade of seventy (70)

or higher on \he Post-Test The wndor manager/owner who scores below \he desired passing grade of se-;enty (70) shall reschedule
for additional training. in defteienl areas. with \he Local WIG /v;Je::y representatNe, 3. To distribute 10 aU ~ ilwolIied in \he Vendor's WIG Program participation all communicaIions IeceNed from \he Local /v;Je::y
pertinent to the ~'s IrNolvemenI in the WIG Program. To instruct cashiers. and all other employees. involved in the Vendor's WIG

Program participation of the eligible foods and \he conect processing of WIG vouchet's.

4. The Vendor will be accoun1abIe for actions of ~ in \he utifization of IIOUCherS or provision of ~lal foods.
as S. To abide by rules 8<'d regulations of Fe<IeraJ, Stale and Local ~ and procedures as cutIined in \he Vendor's Handbook.

T. 1. That the Slate /v;Je::y may deny payments to the Food Vendor for improper food 1IOUChelS or may demand refunds for payments

already made on ~ food IIOUChers.

2. To reimbu<se the State /v;Je::y within thirty (30) days of notiftealion for amounts paid by the State Aqerv::f on WIG Program food

vouche<s processed by the Vendor whictl are aboIie \he normal shelf price of foods.
U. To aIlaw rep<esentatil.es 0( \he Local. State. Federal ~ to moni\()( \he Vendor's store in an unannounced manner at arry time the

store is open for business. AU records pertinent to \his Agreement win be made available for review by the representatNe of the agency.

V. That -.dor ~ are the property 0( \he Stale of Gecxgia and 1hat said stamps will be returned to the W1C Program imme<lCatety upon

form<.::a. termination/suspension/disQualiftealionlYOlunlary withdrawal from program participation.
W. 1. That \he vendor or \he Yendor's employee(S) will not reimburse WIG participants or exchange W1C food items. especially infant

when W1C vouche<s we<e used for the pun::l1ase unless:

a Notified in writing by a health department representatNe,

b. The vendor is exchanging a WIG purchased item(s) due to inappropriately selling out-of-oate W1C foods.

2. That any out-of-oate foods wilt be renlOIIed from stock and replaced with foods that have expiration dates wtIich do not exceed the

period of no<mal expected usage.
X. That arrt Vendor diSQUalified from another FNS Program shalt be disqualified from participation in the WlC Program for the same period of

time, up to three (3) years.

Y. A Vendor who commits fraud or abuse of the program is liable to prosecution under applicable federal, state or local laws. Those who

have willtuily misapplied, stolen. or frauc:lulentty obtained WlC funds shan be subject to a fine of not more \han S 10.000. or imprisonment

for not more lhan fNe (5) years. or both.

AA 10 notify the Local IvJeocY of changes in management or when \he Vendor ceases OJ)eCation or ownership changes. This Agreement is null

and void if ownership changes.

AB. State of Georgia or Local Sales Taxes will not be collected on food items purchased w~h WIG vouche<s.

AC. To declare lhat neither the -.dor/owner, the vendor's manager(s). or the lIelldor's other employee(s) is related by blood or marriage to

arry WlC representative, unless otherwise re...ealed in writing, upon execution of the contract/agreement or within the contract period, (space

provided on page three of this contract agreement for disclosure of relatives)..

AD. To visibly disPlaY the vendor's store name on the outside ot the store building/facility.

AE. To abide by the U.S. Patent and Trademar1<. Laws. which prohibCts unauthorized use of the WlC 3Cf00yffi and logo (refer to Registration

Number 1,630. 68. provided in.2 U.S.C. t876. 15 U.s.C. 1051 et. seq. and 7 GFR Part 246)

Form 3771 (Rev. 695)

Routi:"19: Vlhi!e - Slate WIC Office. Yellow - Local Agency. Pink - Vendor

VN - 35

GA WIC PROCEDURES MANUAL FY '96
VENDOR AGREEMENT
WlC VENDOR NUMBER

Attachment VN-4 cont'd
Page30f 3

Name and TItle 01 <elative that represents the Georgia WIG Program Of ~ by the Georgia WIG Program:

OffICe address 01 relaliYe that represents the Georgia WIG Program ()( employed by the Georgia WIG Program:

Phone Number (oI1icel: ('-_-'~

_

(Please attach additional pagels) if necessary)

It. THE LOCAL AGE!:lev HERESY AGREES AND COVENANTS f>S FOlLOWS:

A To instnJc:l the Vendor upon entry into the program of the appropriate procedures to process WlC \Iouchels.

B. To provide the Vendor with the cunent list 01 foods approved for disbu<sement to W1C Program participants and to issue updates to this

Food Us! as they ocaJr.

.

C. To provide educational material about the W1C Program to the Vendor. O. To instnJc:l W1C pa<tic:ipams and proxies in proper use of WIG "OOChers.

E. To ensure that an authorized participant 0< proxy signature is affixed to 3lT'/ manual \'OllCher prior to releasing the \'OllCher for redemption.

F. To notify the Vendor with a coPY 01 any changes in "OOChers 0< use of \'OllChers and at'tf changes in the Federal and State Regulations

that may affect the Vendor. and to provide the Vendor with a coPY 01 any WIG regulation(s) Of policy issuanoe(s) affe<:ting the Vendor's

participation in the WlC Program.

G. To assist the Vendor with at'tf problem relating to the WlC l'rogra.".

H. To provide the Vendor with a uniquely numbered stamp.

Ill- BOTH PARnES AGREE AND COVENANT AS FOlLOWS:

A That no conffict 01 inte<est exis1s between the Vendor and the Local Agercy (See Section I. AC.). B. Not to discriminate for reasons 01 age, taee, color. sex, national origin Of hancIi<::ap. C. The Vendor has the right to appeal at'tf decision made by the Local Agercy affecting the Vendor's abifoty to participate in the WlC Progran
under the lenns 01 this Agreement.
0. The period 01 this Agreement is set forth on the signature page. New agreements will be executed each year. E. This Agreement shall become nun and void in its entirety upon any changes 01 ownership of Retailer.
F. This Agreement may be canceled by either party with thirty (30) days written notice. G. In the ENent of termination of funds by the funcfmg agency to the State Agercy fo< the WlC Program. this Agreement terminates immeOl3tely H. That neither the LocaI1qe::y 110< the Vendor have an obligation to renew the Vendor Agteement. I. This agreementIcontJacl does not constitute a license 0< property interest The relationship between the local 1qe::y and the Ver..:l<...
ends with the expiration date 01 this agreement/contract.

. 1V. SANCTIONS AND APPEAL PROCEDURES:

A SANCTIONS Vendors shall be disqualified from WIG Program participation lor a period of up to three (3) years if violations ooc:ur during a compIianc, pu:hase. monitoring visit by a W1C representative. or Food Stamp Program participation. Procedures for imposing :he sanctions are outfine< in the Retail Vendor Handbool<. At"f vendor disqualified from WlC participation may be disQualifoed from Food Stamp Program participation
ReIer to 7 CFR 278.

B. APPEAl PAOCEOURE Vendors are enfitled to a fair hearing upon disqualification from the WlC Program. At"f vendor reQUeSting a fair hearing must contact tho Local A/;Je<'cy by telephone. and contact the State WlC Office in writing within fifteen (15) days alter the action which is being taken.

V. TERMINATlON POUCtES:

A. A Vendor shall be terminated from W1C Program participation if the store is NOT licensed by the Georgia Department of Agricuttur",. B. A Vendor shall be terminated lrom WlC Program participation if the store is not eligible for Food Stamp Program participation/allthorizatlo
0< a Vendor is wilhd<awn from Food Stamp Program participation.

Fo<m 3771 (Rev. 6-95)

Routing: White State W/C Office. Yellow Local Agency. Pink. Vendor
\TN -36

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-5

MILITARY COMMISSARY AGREEMENT

WIC Vendor Agreement Between Military Commissaries and Local Agencies for
The Special Supplemental Food Program For Women, Infants, and Children (\VIC)

T he purpose of this WIC vendor agreement is to oudine the basic responsibilities of WIC local agencies and military commissaries which have been authorized to be WIC food vendors.
1. In order to be an authorized WIC food vendor, the commissary shall fulfill State criteria for authorization and shall sign an agreement with the Local Agency.
2. The Local WIC Agency shall agree that commissaries shall be reimbursed for the provision of authorized supplemental "foods to participants, based on the standard commissary price system of procurement costs plus a percentage surcharge. The Local Agency shall further agree that commisSaries are only obliged to serve active or retired military personnel and their
dependents~
3. The Local Agency shall provide the commissary with a list of approved WIC supplemental foods. The Local Agency may not direct the commissary to carry a specific brand of merchandise, if that product does not fall within the items authorized for sale in commissaries or if the commissary carries an equivalent product from the approved list ofWIC foods.
4. The commissary shall comply with applicable Federal regulations and Local Agency guidelines for WIC food vendors, such as: provision of supplemental foods to participants, completion and submission of food instruments (also called WIC vouchers), acceptance ofWIC vendor training within funding/personnel constraints,

and other Local Agency guidelines agreed to by the appropriate commissary headquarters except those excluded in item five (5) below. The commissary shall not discriminate on the basis of race, color, national origin, sex, age, or handicap.
S. In \;ew of Federal immunity from State claims or review, the Local Agency may not conduct on-site monitoring reviews of commissaries (except upon invitation by the constituted military authority) nor require claims to be paid. However, the State Agency may review redeemed food instruments prior to payment. If the food instruments are found to contain errors or omissions, payment may be denied unless or until further justification or correction is provided by the submitting commissary.
6. If the State Agency wishes to further pursue problem resolution, it shall refer the case to the Food and Nutrition Service (FNS), U.S. Department ofAgriculture. FNS, in conjunction with the Department of Defense, may conduct on-site monitoring reviews and submit claims to commissaries for the WIC Program.
7. Local Agencies are authorized to use the general guidelines above in writing agreements with commissaries, based on Section 246.10 (f) of WIC Regulations. Authority: Section 17 of the Child Nutrition Act of 1966, as amended (42 U.S.c. 1786): WIC Program Regulations (7CFR Part 246).

Vendor Name (Print) Signature of Authorized Military Personnel Date Signed

DistricdUnit

Vendor #

Signature of Local Agency Representative

VN -37

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-6

- _ - PHARMACY AGREEMENT -.

.,.-.. ~.PI'ogfam

.

'Sl'Ecw. SUI'PI..EIolEKW FOOO _

f'OR WOMEN. ..nwrs & CHlUlREN)

PHARMACY AGREEMENT

Page 1 of 3

This Pharmacy/Provider Agreement is made by and between the Georgia Department of Human Resources. Oivis;on of Public Health. Health District

_ _ _ . Unit

. (hereinafter referred to as \he lDcal Agency) and

_

(hereinafter referred to as the Vendor) to provide a mechanism for the distnbution of S{:JeCiaI ~taJ formula to eligible WIC participants in the

OO<Il1ly(ies) included in this Health District Jurisdiction. This agreement wiU become e!fec:tilo'e on

_

and witl terminate on

_

WlC VENDOR NUMBER

The undersigned represents the Vendor as \he sole proprietor or \he The undersigned represents the LocaJ Agency and has the authority to pharmacy manager to contract for and on behalf d \he Vendor identif.ed contrael for and on behalf of said agency. below. (Signature MUST be of owner or pharmacy manager.)

SiQnat...... PNnnaey 0..- or " " ' -

Dole

Sgnawoeoll.OCOllqtrq_ed_

City
City
PURPOSE:

(Print) Name '" PNnnaey Owner o r , - -

Name .. _

(Plwmacy)

(Print)Name"I.ocoIIqtrq~_
LocoI_ Name '"

. "'"'""o-.._p.o._ .

1.\ai;ng~._PO.1lox

S!ree1 Location of PNrmacy Street Adc:kess

- -Stale
....... '" Phannac:y Owner(. _ _ _I

Zc>Ccde

City
--
e-""", ....... Sales

- -Slale

Zc> Cede

_ _ _ Soles

......,........

- SQuaIe Foocage '" S10te

- # .. casn ............
or

-

SIaIe

Zc>Cede

-~--

SociaI5eclriy _ _

This Agreement is for \he IlUfPC)Se d providing a mechanism for the dislribtution d certain listed fonoola to erogible partq:lants and \he redemption d negotiable food instruments for \he puldlase 01 ll8id formula items. The Vendor is retained solely for \he purpose

set forth herein and shall nd be considered as an ernployee or agent d \he Department.

THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT.

BANK NAME IollDRESS
BANK NAME !>DORESS

Form 3782 (Rev. 6-95)

Routing: While - State WIC Office, Yellow - Local Agency, Pink Vendor
VN -38

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-6 cont'd

PHARMACY AGREEMENT
WlC VENDOR NUMBER

Page 2 of 3

lliE PHARMACY VENDOR HEREBY AGREES AND COVENANTS AS FOLLOWS:

A. Upon notification from the Local Joqerv;;y, to supply, within a time period agreed upon by the Pharmacy and the Local Agercf, the necessary

supply of any one of the "'Special Infant Fonnulas-.

B. That an p<ices will be dearly mar1<ed either on the food item or prominently displayed.
c. To accept WlC YOUChers for payment of the purchase of only eligible WIG formutas. In addition. the YeOdor must accept an valid WlC

vouchet"s.
O. To accept no WIG YOUChers as payment on past or present credit account(s).

E. To accepI no WIG YOUChers from participants presented after thirty (30) days from the issuance date or prior to issue date shown on the

voucher.

F. To accepl only \'OUChers which contain a Georgia WIG Program SEAL

G. To refuse acceptance of any food instrument on which any alterations have been made.

H. To sell WlC formula at or below the normal pharmacy shelf price, but not to exceed the maximum amount listed on the \IOUCher.

l. To permit WlC program participants to purchase eligible formula without making other purchases and to accord such participants the same

courtesy given to other pharmacy alStomers.

J. To keep an information confidenfial on WlC participants.

K. To direct questions conceming payment, program operations. etc. to the Local ~ participants will not be contacted concerning these

or other problem areas. (VenOOrs shall not seek restitution from participants lot \'OUChers not paid by the State.)

L To ensure that no exchange of money between the pharmacy and participant takes place during a WlC YOUCher transaction.

M. To aHow no rainchecks or exchanges of any \IOUCher for cash, aedit. coupons, stamps. premiums. or nonlisted formula: however, a Vendor is not precluded from giving or accepting coupons. stamps. or p<emiums with purchases as if purchased with cash.

N. To obtain at the time of purchase an original alStomer signature on the WlC voucher and request the participant to show a WlC identification

card before the purchase of WlC lormuta can be completed. If the customer is unable to show a WlC identifocation card bearing the same

signature as signed on the YOUCher, the Vendor should rot accepI the WIG 1IOUCher as payment lot the formula.

O. To insert. in ink, the actual cost of the WlC formula on the WlC YOUCher lace at the time of purchase in the presence of the customer.

P. To stamp an WlUChets with the authorized YeOdor stamp (proW:Jed by the Local Agency) before depositing in the bank and to deposit all WlC YOUCheiS in a timely manner, preferably within fifteen (IS) days of redemption but rot more than sixty (OO1 days from the date of

issuance shown on the YOUCher lace.

Q. 1. To distribute to all employees involved in the Vendor's WIG Program participation alt communications received from the Local Agercf

pertinent to the ert1Plo\Iee's InvoIvemenl in the WlC Program. To instruct cashiecs, and all other ert1Plo\Iees, involved in the Vendor's WIG Program participation cI the eligible fonnula and the correct processing of WlC 1IOUChe<s.

2. The Vendor wiD be accountable lot actions of ernpI<))'ees in the utilization ofllOUChe<s or provision of StJPl)Iemental foods.

R To abide by rules and regulations of Federal. State and Local Ageocies and all procedures as outlined in the WIG Pharmacy Handbook.

S 1. That the State Agercf may deny payments to the Vendor for improper toed YOUChers or may demand refuflds lot payments already

made on ~ IIOUChe<s.
2. To reimburse the State Joqerv;;y within thirty (30) days of nolifocation lot annmts paid by the State Agercf on WlC Program food

IIOUChe<s processed by the Vendor which are above the normal sheIt price of focmula.

T. To allow representatives of the Local, State, or Federal Agercf to monitor the vendot's pharmacy in an unannounced manner at any time

recoros the pharmacy is open for business. All

pertinent to this Agreement win be made available lot review by the ~ of the

agency.

U. That vendor stamps are the property of the State of Georgia and that said stamPs will be retumed to the WlC Program immediately upon

terminationlsuspensionldisQualication/voIuntary withdrawal from program participation.
V.I. That the wncIor or the IIefldo(s employee(s) will not reimburse WlC participants or exchange WlC formula. when WlC IIOUChe<s ...ere

used for the purchase unless:
a Notified in writing by a health department representative.

b. The wncIor is exchanging a WlC purchased item(s} due to inappropriately selling out-ol-<late WIG fonoola.

2. That any out-of-date tonnula will be n!mOYed from stock and replaced with fonnuIa that haIIe expiration dales which do rot exceed

the period of normal expected usage.

W. That any Vendor cflSQUalifled from another FNS Program shaH be disqualified from participation in the WlC Program for the same period of

time, up to three (3) years.

..

X. A Vendor who commits fraud or abuse of the program is liable to prosecution under applicable federal, state or local laws. Those who

haIIe willfully misapplied, stolen, or fraudulenlly obtained WlC funds shall be subject to a rme of not more than $10,000, or imprisonment

for not more than fNe (5) years, or both.

Y. To rotify the Local Agercf of changes in management or when the Vendor ceases operation or ownership changes. This Agreement is null
a and void ownership changes.

Z. State of Georgia or local Sales Taxes will not be collected on Iotmula items purchased with WIG 1IOUChe<s.

AA. To declare that neither the YeOdor/owner, the vendor's manager(s), or the vendor's other empioyee{s} is related by blood or marriage to

any WIG representative, unless otherwise revealed in writing. upon execution of the contract/agreement or within the contract period, (space

provided on page three of this contract agreement for disclosure of relatives).

AB. To visibly display the vendor's store name on the outside of the store building/facility.

AG. To abide by the U.S. Patent and Trademark Laws. which prohibits unauthorized use of the WIG acronym and logo (refer 10 Registration

Number 1,630,468, provided in 42 U.s.C. 1876, 15 U.S.C. 1051 et. seq. ard 7 Grn Part 246).

Form 3782 (Rev. 6-95)

Routing: White - Stale WIC Office, Yellow - Local Agency, Pink - Vendor

VN -39

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-6 cont'd

PHARMACY AGREEMENT
WlC VENDOR NUMBER

Page 3 of 3

Name and Tille of relative that rep<esents the Georgia WIC Program or employed by the Georgia WIC Program:

Office address of relative that represents the Georgia WlC Program or employed by the Georgia WIG Program:

Phone Number (offlOe): ('--_--!

_

(Please attach additional pagels) if necessary)

II. THE LOCAL AGENCY HEREBY AGREES AND COVENANTS AS FOLLOWS:

A. To instruct !tE Vendor upon entry into the program of the appropriate procedures to process WlC Vouchers.

B. To provide the Vendor with the current list of formulas approved lor disbursement to WIC Program participants and to issue updates to this

Formula Us! as they occur.

C. To provide educational material about the WlC Program to the Vendor.

D. To instruct WIC participants and proxies in pcoper use of WIC vouchers.

E. To ensure that an authorized participam or proxy signature is affixed to any manual \lOUChe( prior to releasing the voucher for redemption.

F. To notify the Vendor with a copy d any changes in voucher.; or use of vouchers and any changes in the Federal and Slate RegulationS

that may affect the Vendor, and to provide the Vendor with a copy of any WlC regulation(sl or policy issuance(s) affecting the Vendor's

participation in the WIG Program.

-

G. To assist the Vendor with any problem relating to the WlC Program.

H. To provide the Vendor with a uniquely numbered stamp.

III 80TH PARTIES AGREE AND COVENANT AS FOLLOWS:

A. That no conflict of interest exists between the Vendor and the local Age<'cy (see Section l.. AB.).
B. Not to discriminate tor reasons of age, race. color, sex. national origin or handicap.
C. The Vendor has the right to appeal any decision made by the local Age<'cy affecting the Vendor's ability to participate in the WIC Program under the terms of this Agreement.
D. The period d this Agreement is set forth on the Signature page. New agreements wiU be exealled each year.
E. This Agreement shafl become rUl and YOid in its entirety upon any changes d ownership of Pharmacy.
F. This Agreement may be canceled by either party with thirty (30) days written notice.
G. In the event of termination of funds by the funding agency to the Slate Age<'cy lor the W1C Program, this Agreement terminates immediately. H. That neither the Local Agerey nor the Vendor haIie an obligation to renew the Vendor Agreement L This agreement/contract does not constitute a Iioense or property interest The relationship belweenthe Local Age<'cy and the Vendor
ends with the expiration date of this agreement/contract.

IV. SANCTIONS AND APPEAL PROCEDURES:

A. SANCTIONS
Vendors shall be disQuaIifoed from WlC Program participation for a period of up to three (3) years if violations occur during a compliance
pUrchase. monitoring visit by a WlC rep<esentative, or Food Stamp Program participation. Procedures for imposing the sanctions are outlined in the WlC Pharmacy Handbook. Arry vendor disQualifoed from WlC participation may be disqualified from Food Stamp Program participation.
Refer to 7 CFR 278.

B. APPEAl PROCEDURE Vendors are entitled to a fair hearing upon disQUalification from the WlC Program. Arry vendor reQuesting a fair hearing must contact the Local Agercy by telephone, and contact the State WIC Office in writing within fifteen (15) days after the action which is being taken.

V. TERMINATION POUCIES:

A. A Vendor shall be terminated from WlC Program P?r1icipation if lhe store js NOT licensed by the Georgia Department of Agriculture. B. A Vendor shall be terminated from WlC Program participation if the store is not eligible for Food Stamp Program participation/authorization
or a Vendor is withdrawn from Food Stamp Program participation.

Fo<m 3782 (Rev. 6,95)

Routing: White - Slate WIC Office, Yellow - Lccal Agency, Pin/< - Vend",

VN -40

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-7

ROLLING STORE ADDENDUM

Georgia Depart:rn<irit of Human Resources Division of Public Health
WICProgram *Vendor Agreement Rolling Store Addendum

Contract year

to

_

Rolling Stores participating in the WIC program must meet the following requirements:

1. Each operating truck must be refrigerated and must be licensed by the Deparunent of Agriculture

GA Deparunent of Agriculture #

Truck Tag #

_

2. Submit a route schedule to the State WIC Office at the time of application. An updated schedule must be submitted within 30 days pnor to implementation date of changes. (Route Schedule attached)
. 3. Submit the loCation of the food storage facility to the Local WIC Office and the State
WIC Office at the time of application.

4. Must notify the Local Agency and the State WIC Office when new trucks are added to the fleet.

5. Vendor will operate only in county(ies) served by the district in which he/she is applying for vendor certification.

6. Vendor must visibly display the name of the rolling store on the outside of all trucks operating to accept WIC vouchers..

Vendor Name (Print)

DistrictlUnit

Vendor #

Signature of Owner or Manager

Signature of Local Agency Authorized Representative

Print Name of Owner/Manager

Prim Name of Local Agency Representari\'e

Date

Date

Continued authorization of Rolling Stores is currently under review. Therefore, tllis Vendor Agreement Rolling Store Addendum is null and void if Rolling Stores are eliminated from \,VIC Program participation.

VN -41

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-~\

ROLLING STORE ROUTE SCHEDULE FORM

Georgia DeparoneD.t of Human ResOurces
State WIC Office *ROLLING STORE ROUTE SCHEDULE

Vendor name:

County

Street Location

.. .

I
I
I

_
Delivery Day
I I I
I
I
I
I I I I I I I I I I I I I I
I
I
I
I
I I
i,

City_--------

I I TIme Begin Tune End Tag Number 1 i
I
i

I

!

I

I i

I

I
I
I
I

I

I

.

,,

I !

I j

i
i

\
:
I
i I
i I
;
I
\,
! I

.
!

j

i

I

'Continued authorization of Rolling Stores is currently under review. Therefore, this Rolling Store Route Schedule is null and void if Rolling Stores are eliminated from WIC Program participation.

VN -42

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-Q

VENDOR TRAINING CHECKLIST

Georgia Department of Human Resources Georgia.yrIC Program
VENDOR TRAINING CHECKLIST

WIC VENDOR f\JUMBER

1'---_-
~YES-I I,--_N_O---JI I,--_N/_A_
I. Discussed purpose of vendor training for new and current vendors and also who is required to attend vendor training. (See Vendor Agreement-L(R)(l-4) and the Vendor Handbook.)
2. Discussed purpose of the WIC Program. (See Vendor Handbook and Vendor AgreemenL)
3. Discussed WIC approved foods. (See page I of the Vendor Handbook.)
4. Discussed minimum inventory requirements. (See page 2 of the Vendor Handbook.)
5. Examined and discussed WIC Vouchers in detail. (Refer to the Vendor Handbook.)
6. Discussed procedure for processing WIC vouchers. (Refer to the Vendor Handbook and Vendor Agreement-L(D-I) and (M-Q).
7. Discussed checking Qut WIC customer and WIC LD. Card. (Refer to ihe Vendor Handbook and Vendor Agreement-L(O).
8. Discussed payment ofWIe vouchers. (Refer to the Vendor Handbook and Vendor Agree.ment-L{T)(I) and (2).
9. Discussed procedure for processing bank-returned vouchers. (Refer to the Vendor Handbook.)
10. Conducted in-depth discussion of compliance monitoring and sanctions. (Refer to the Vendor Handbook and Vendor Agreement L(S) and IV.)

11. Discussed purpose of Vendor Agreement and who is authorized to sign the agreement. (Refer to the Vendor Application Booklet and Vendor Agreement page 1 of 3 and L(RXI).

12. Read and discussed each item listed on the Vendor Agreement.

13. Discussed how to contact Local and State \VIC representatives. (Refer to the Vendor Handbook and the Vendor Agreement.)

14. Completed the Federal Fiscal Year Vendor Training Post-Test.

(Refer to the Vendor Agreement-L(R)(2).

IS. Other (Specify)

_

I have received a copy of the WIC Vendor Handbook and the Sanction Point System. I acknowledge in-depth discussion of the Handbook, the WIC Vendor Agreement, and all other items checked "Yes" as outlined by the Vendor Training Checklist above.

Comments:

_

OwnerlManager

Name Owner/Managa- (PRINT)

Name of Vendor (S,ore)

Moiling AddressStreet. Location. P.O. Box

City

State

Zip Code

Local Agency Authorized Representative

Name of LocaI Agency Aulhoriz.e4 Representative (PRINT)

Name of LocaI Agency

Moiling Address Street. Location. P.O. Box

City

State

Date Zip Code

Form 37$7 {R~. 6-951

ROUTING: White SWO Yellow-District Pink-Vendor
VN -43

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-lO

VENDOR TRAINING INFORMATION FORM
GEORGIA DEPARTMENT OF HUMAN RESOURCES
GeOrgia WIC Program
VENDOR TRAINING INFORMATION FORM

DISTRICT LOCATION OFTRAINING TRAINING CONDUCTED BY

UNIT

DATE

_
~
_

LIST OWNER/STORE MANAGER WHO DID NOT ATTEND ANNUAL TRAINING AND VENDOR AGREEMENT WAS NOT RENEWED.
(fO BE TERMINATED)

VENDOR #

VENDOR NAME

NUMBER OF STAMPS RETRlEVED

IF 'NO' COMMENTS

(PLEASE ATTACH A COpy OF THE TERMINATION INPUT FORM, SANCTION POINT SYSTEM FORM, VENDOR AGREEMENT, TRAINING CHECKLIST, VENDOR POST EVALUATION TEST, AND THE VENDOR STAMP IF AVAILABLE)

FORM 3758 (REV. 3-95)

ROUTING: WIIlTE - STATE WIC OFFICE YELLOW - DISTRICT
VN -44

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-II

VENDOR TRAINING SIGN-IN SHEET
Georgia Department of Human Resources DIVISION OFPliBLIC HEALTH ,'Ok'OFFicE
VENDOR TRAINING INFORMATON FORM
SIGN-IN SHEET

DlSTRICT

_ UNIT

TYPE OF TRAINING: ANNUAL 0

FOLLOW-UP 0

LOCAnON OF TRAINING

VENDOR NUMBER

STORE NAME

_

DATE

_

MAKE-UP 0

OTHER

_

TRAINING CONDUCTED BY

PRINT OWNER / MAN AGER NAME

SIGNATURE/TITLE

.
-

Form :~7 :i(, (He ..... -; .~It)

1{()(;Tl:-;C, WHITE STATI'; \\'1<: oFFICE

n:l.1,OW, D1STH1('l

VN -45

GA WIC PROCEDURES MANUAL FY '96 VENDOR HANDBOOK

Attachment VN-12

Georgia
WIC
Vendor Handbook
Georgia Department of Human Resources
FFY 1996

VN -46

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Contents

What is WIC

1

WIC approved food list .. :

1 0

What foods can a WIC customer

(participant) purchase

2

Minimum inventory requirements

2

The WIC food vouchers

3-4

Processing WIC vouchers

4

Voucher code numbeI'S.2Iid mesSaOges

5-9

Checking out the WIC customer

9-10

Important notes

__

_ 10

Voucher payment policy. '

10-11

Voucher payment procedure

11

Vendor Training

11

Compliance performance
Sanctions,d~qualifications,and
terminations................ _.. _

11-12 12-15

About the WIC acronym and Logo

15

Termination procedures

15 0 _

HearinglAppeal procedures

15 0 0

Change of ownership

_ 15 0 _

Changing store location . . . . 0 0 0 0 16

Where to get more information o 0 16

VN -47

GA WIC PROCEDURES MANUAL FY t96

Attachment VN-12 cont'd

VENDOR HANDBOOK

WhatIsWIC?
W IC stands for Women, Infants, and Children. TIle WIC program is funded by the U.S. Department of Agriculture and is administered in Georgia by the Department of Human Resources through state., district, and local health offices.
WIC provides important food to pregnant women and their infants and/or young children. Proper nutrition at the beginning of life may help prevent serious

healthproblems. "''IC gives children a chance to grow up healdlY and lead active., productive lives. WIC program participants have been examined by health professionals who detennine the need for supplemental food and nutritional guidance.
The participants receive vouchers for specific kinds of
highly nutritious foods. These vouchers are redeemed by participating grocers or pharmacies (vendors) who have signed an agreement to follow all WIC program requirements.

WIe Approved Foods List
The following list of foods may be purchased using WIC vouchers:

Food Item

Brand or Type

Cont:ainerlPkg. Size Cannot Buy

Milk (PasteUrized)

"''hole, Skim, 99% Fat Free (1%). or Low Fat (2%)
<L= f.xp=ive B=d Only)

Acidoph.ilus. Enjoy, Laaaid, Lactaid 100 Nutrish or Dairy E= Evaporated . Powdered

i
I.

. Cheerios, Chex (Cnm. Rio:,Whcotl.
Crispy Critters, CoWltIy Com Flakes, Kix, Nabisco QuickCream ofv.'heat(R<:guluRa.ocl.

Product 19.Jim Dandy Quick Grits (Iron Fonificdl,

Minute 3 Brand Instant Oatmeal (R<:guIu Ra.ocl.

Harvest Instant Oaaneal (R.gubl"~

Quaker Instant Grits or Oatmeal (R<:guIu~

Total-Com FWces. KdIoggs.SpeciaI KorCom Flilis

One Gal Size ONLY (E=pcion: 112 Gal. or QlS. of Enjoy. Laaaid, and/or Acidophilus. Laaaid 100. Nutrish
Dairy Ease. 12-=Cans
Evaporated, 3 or 5Qt- Boxes Powdered)
and Nine (9) Oz. Sizes Above ONLY
Can pun:h,ase more than one (1)
typeIbrand ofcernl as \ongas the amount does not~<M:rdie quantity on the front ofthe vooc:her

F'1avoRd Milk, Buamnilk.or Goat'S Milk
Eight (8) Oz. or Less Size Boxes

American (Sliood BIocIc), Cheddar (IlIoc:k),
Colby (BIocIc), MontereyJack(Block), Mo=rella(llloc:k),
Kraft Deluxe (sliced & singlywrappcd)

Nine (9) Oz. Up to 16-0z. (One [IJ Pound) SIZe ONLY

Oteese Food, .Sbreddcd or Deli O=se. :and/or 2-8 0z.PIr:gs.. tOr 1 160z. Pki_(n08
~of

Juice(lOO% USRDA
Viamin C Fonified)

46-OzCans or 12 Oz. Cans Frozen ONLY

Juice Drinks, Fresh Squeeud
Juice, SIilgIeSrmg.
Sizes, InEmtJuio:s.
Juices With Sup
Added

Eggs (GmeA Lorg<ONU1 Least Expensive B=d Only

One (I) Do7.en

AnyOtherSlZeIQnty.

Dried PeasIlleans

Any Brand Without F1avoring Added

One (1) POWld Size ONLY

Any Other SlZeIQnty.

Peanut Butter

Any Brand WithoutJeIly Added or Honey Spread 18 Ouncejars ONLY

AnyOther Siz.elQnty.

J:nf:mt Formula

As Listed on the From of the Voucher

i J:nf.mt Cereal (BoxcsOnho)

Beech Nut, Gerber, Heinz

.\

i

____________~ ..... _.__. .

.

As Listed on Front ofVoucher Unlisted on Voucher

Dry Cereal in g Ox.. Sizes ONLY Any Baby Food in

Jars orAny Dry

....+

._.

Cereal With Fruit

.

+o::.r..:.F..:.orm..;.:.:.:u1=.:a:...A:...d..:.dcd.:.;:....-1

TWla
CarrolS

I Least E.>.-pensi\'e Brand/Water Packed ONLY ----!----~:rcsh, "''hole

6 OWlce Cans ONLY

Tuna Packed in Oil

lone (I) Lb Pr=kd Plastic BagONLY\ Bulk, Frozen, Canned, Shredded, or Bal:.>;Carrots

1

VN -48

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

What Foods Can a WIC Customer (participant) Purchase?
The VVIC participant may become a regular cus-

tomer Oat a participating store and purchase any groceries there. However, the WlC vouchers can only be used to purchase specific types of food. Each voucher lists the food that can be purchased.

WIC Minimum Inventory Requirements
The following is a list of the minimum inventory requirements for WIC vendors which outline the required quantities, sizes, types or brands, which the store must carry in order to become or remain a WIC vendor.

Food Item

\

Quantity ,

I

Size

I

Number of Types!Brands

Milk: (Pasteurized)

20

1 GaI.Jug

1 Brand

Note: Quantity may include whole, 2%, 1%, and skim milk in the gallon size container only.

Cheese:

I

16

i

1 Lb. pkg.

Eggs: (Grade A Large)

16

I 1 Doz. eggs per carton

I

Juice:

I

24

I

46oz.can

12

i 12 oz. frozen container

I

Cereal:

30

9-20 oz. box

Note: At I~st two (2) types of cereal must be in 12 oz. size.

2 Types 1 Brand
22y~ pes
4 Types

PeaslBeans:

8!

Peanut Butter:

8

i

I

Tuna:

8

Note: Must be packed in W2eer

,I
I

Carrots:

4

i I

lib. pkg. 18 oz. jar 6 oz. can
lib. pkg.

2 Types 2 Brands 1 Brand
1 Brand

Fonnula: (With Iron)

186+

13 oz. can

I Brand

Contract brand of formula only. Vendor must be able to supply soy, powdered, ready-eo-feed, concentrate,

LactO Free, or a different brand of formula upon request.

+ Vendor must seock a minimum of 32 cans ofProsobee (soy base Contracted brand) formula, 16 cans ofLacto Free (laceose

reduced Contracted brand) formula and 138 cans of Enf2mil (mill:: base Contracted brand) formula.

Note: Low iron formula does not meet WIC minimum inventory requirements for formula.

Infant Cereal:

12

!

Noee: At least one (I) type of inf2nt cereal muse be rice.

8 oz. box

2 Types

Pharmacies are exempt from the minimum inventory requirements, but muse meet the maximum pricing criteria.

In an effort to continue serving as many WIC eligible Georgians as possible, the following food items must be purchased in the following quantities and/or sizes:
MILK: Gallon size container only, with the exception of lactose reduced milk (Enjoy, Lactaid, Nutrish, Acidophilus, Lactaid lOa, and Dairy Ease).
CHEESE: Nine (9) oz. to one (1) pound package(s) of cheese only, no eight (8) oz. packages of cheese are allowed to be purchased.
JUICE: Only t\velve (12) oz. containers and
2

forty-six (46) oz. cans of juice may be purchased.
Combinations Allowed:
Women and children may receive vouchers for milk, cheese (not cheese food), eggs, certain brands of cereal with a high iron content, fruit juice (not fruit drink) which is high in Vitamin C, dried beans/peas, or peanut butter. Infants may receive iron fortified formula, infant cereal, and juice.
These food prescriptions are carefully selected, and substitution of other foods is prohibited. Vendors receive a new list of the approved foods any time changes are made.

VN -49

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Vendors are required to keep a minimum inventory of the approved foods and offer them at competitive prices (see page 2).
The State WIC Office will mail route schedule fonus to each rolling store vendor each quarter. This route schedule will be submitted quarterly and should be returned by November 15th (1st quarter), February 15th (2nd quarter), May 15th (3rd quarter), and August 15th (4th quarter). Continued authorization ofRolling Stores is currently under review. Therefore, the

above procedure and policy is null and void if Rolling Stores are eliminated from WIC Program participation.
The WIC food vouchers
The voucher for WIC foods is a check and should be redeemed just 3S carefully. When a voucher is properly redeemed, the vendor will receive credit for the amount of purchase by depositing it in hislher bank account. The vendor is responsible for any mistakes that cashiers
(Continued on page 4)

There are three types ofWIC vouchers, computer generated, standard manual, and blank manual.
Computer generated voucher: All information on this voucher is computer printed.

.we~1n

Ie l'

~

.... ., "81 I J 9'161 601 7831 11 PARTICIPANT'

"OttN Q

.8,..195 ~DAY lOU6t:

'112't51~.2e~ 1

GEORGIA WIC PROGRAM
DEPARTIENT OF HUMAN RESOURCES

~Nl
29511284

~. . .J.C. _ORliIA PIOGRAM

PAYTO'n1EOOoeAOI'~~:"":='.~V:=-
i'qQa E'''OCA~f coo ~07 VOUCHER' COOE 27 "~: 2 GAt. (GU 8-12 01 CtilS EYAP

fORn-S.OT 80X

---

.ttlla::

oa 1-12 Ol elM F~OZE"

1~6 OZ C~'f

c~.t;: UP TO ~6 OUNCES

1 L8 ~~EO BEAWS/PEAS (OR) Ie 01 P-UT SUTTEft

fMTDAY
1O~

nnl,"

I . J o a n s ~MlISf lliP06ITlY ..

$030.

llO<iAM C9IllI

r,,:;';';;;;;;:) t t f ~"""foM'e I
'''''IN... '!'......
"--=-_..1

YOURlWlY NEED8 SHOTS AT 2 MotmfS, 4 MONTHS, ~~. .

..

.- &lilOHT1iS,t51o!0HTt<S,I<SYEAR6

STA"!ENC_
~

~?IO VOID VOID YOIO'YOID YO~~ OIn VOID VOID VOID YOlO YOI

UN~ K.cx.m.l. 2q 5 calell" 1:0(; 0 [,81: 00 Ob~ 00"

Standard manual voucher: Manual vouchers are processed in me same manner as computer generated
vouchers. The standard manual voucher has the name, 1.0. number and dates written or typed by the staff at the clinic.

~~I<el
99.9 q981

'Mc.c!.....
II

I e~p I
III

~

~.

ARSTDAY
TO USE

'fi 74342221 4

GEORGIA WIC PROGRAM
DEPARTMENT OF HUMAN RESOURCES

74342221 YOUC>ERNO.

LASt DAY lOUSE

~MllST

16r;"",,,;=~.~Th-En~~.Efl PROGRAM j.flIU.:
lE6~:

1 GAL <OR) 6-12 GZ eNS HAP (~)l-5 QT 8el( 1 DOLEN

COD, ,,-

OEJ'OS{T BY
SOlO.
-.
00l.l..MS cam;

: .It/ICE: 2-12 OZ CANS FRO ZEN ()fl 2-46 OZ CAMS

@:I I

.. ..

..r:~.~-::;-;'I
I : .., .... - I
1 .... '."" I \......_~--_..1

C

iiQJIl4f"lEtTWG ()I"f'(:(,

M='A~R USE OF TtCS

VOUC~rs ~CT TO

J

STATE At.IO FtOEFW. PROSEQJTOH

~telilE.T~YI'lOf\E

~?0I1O0

\'oro
VOID

VOID VOID

VOID \'010

'tOlD VOID

VVOO~l ~

~~?1.,:ll.,222.1l" ~':Ob.l.O b8;: uO Obi 00" Ol~::'

3

VN - 50

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Blank Manual Vouchers
The blank manual voucher has the name, I.D. number, and dates, written or typed by the scaff at

Examples:
1. fK] [2] Correct

0 G 2.

Correct

o [2] Incorrect o ~ Incorrecr

the clinic. The amount of food to be received is also written or typed. Redeem only 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(s). A description of all voucher code numbers are shown on pages 5, 6,

and 7, 8, and 9.

.., .

lIMl::ONO.

11 I 99 9 9gel 9452557 3

I

Cp
III

...."""""'T

GEORGIA WIC PROGRAM OPAATIoIEKl" OF HllIU.H RSO\JII(;ei

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M'Rl)pRUSE OF 'tM$ ~ IS SUBJECT 'TO
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(VOID VOID VOID VOID veto VOI'J

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make with WIC vouchers, so he/she must be sure that they know all WIC voucher redem tion requirements. The scate and local WIC offices can assist with cashier training as needed.
A WIC vendor must accept all valid WIC vouchers. However, no voucher will be redeemed for more than the maximum amount printed on the face of each voucher.
Processing WIe Vouchers
After a grocer IUs signed an agreement with the
WIC program, he/she will receive a WIC Vendor Identification Number and a stamp with this number. After the vouchers are accepted, they must be scamped with this number in preparation for a bank deposit. The vendor should inform his/her bank before or at the time of his/her first deposit that the vouchers can be delivered through the Federal Reserve System to the Bank South of Atlanca, Georgia.
Payment will be assured, prior to the deposit, if:
1. A "VIC program authorization seal appears on the face of the voucher(s),

2. An authorized WIC vendor Stamp appears on the face of the voucher.
3. A tocal amount of the purchase is entered in the presence of the customer.
4. The amount of purchase does not exceed the maximum amount printed on the face of the voucher
5. The participant must use the voucher before the "Last Day to Use" Statement on the voucher. The voucher is not valid if used before the "First Day to Use" or if deposited after the "Vendor Must Deposit By" date.
6. Endorsements should appear at the bottom leftcorner (for manual vouchers only) and right corner of voucher(s). The participant must sign
the area "Sign Here at 'WIC Office," prior to
redemption of manual vouchers and/or sign a voucher register for redemption of computergenerated vouchers. In addition, the area "Sign Here at Grocery Store," should be obtained upon redemption of\.VIC food item(s), All vouchers which do not meet these requirements will be returned unpaid to the vendor.

4

\TN - 51

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

~ \~(JU(. 'I,<rf V<.n1dl<r lU~"'l>J!=C

'.'.

c.><k I

001 CHEESE: UP TO I LB.

JUICE: 1-12 OZ FROZEN OR 1-46 02 CAN

CARROTS: 2-1 LB SEALED PLASTIC BAGS

TUNA:

4~OZCA.NS

I LB OF DRIED BEANSIPEAS

025 MILK: I GALOR4-1202CANSEVAPOR 1-5QTBOX
CHEESE: UP TO I LB
JUICE: 1-12 OZeAN FROZEN (OR) 1-46 OZ eAN I LB DRIED BEANSIPEAS

027 MILK: 2 GAL (OR) 8-12 02 CANS EVAP

(OR) 1-3 QT BOX

JUICE:

1-12 OZeAN FROZEN (OR) 1-46 OZ eAN

CEREAL: UP TO 36 OUNCES

I LB DRIED BEANSIPEAS (OR) 18

OZ PEANUT BUITER

028 MILK:
EGGS: JUICE:

I GAL (OR) 4-1202 CANS EVAP (OR) 1-5 QT BOX I DOZEN 2-120ZCANSFROZEN(OR) 2-'lOZ CAI\'S

029 MILK: JUICE:

2 GAL (OR) 8-120Z CANS EVAP (OR) 2-5 QT BOX 1-12 OZCAN FROZEN (OR)
I~OZ~

030 MILK: - 2 GAL (OR) 8-12 02 CANS EVAP (OR) 1-5 QT BOX
EGGS: I DOZEN JUICE: 2-12 OZ CANS FROZEN(OR)
2-46 OZ CANS

031 MILK: I GAL (OR) 4-12 02 CANS EVAP (OR) 1-5 QT BOX
CHEESE: UPTOILB JUICE: 1-12 OZ CAN FROZEN (OR)
1-460ZCAN

032 MILK:
EGGS: JUICE:

2 GAL (OR) 8-12 02CANSEVAP (OR) 2-3 QT BOXES I DOZEN 2-12 OZ CANS FROZEN (OR) 2-460ZCANS

033 MILK: 4 QTS (OR) 2-1/2 GAL
AODOPHILUS, ENJOY. LACTAID, NtTrRISH, LACTAID 100, DAIRY EASE CHEESE: UPTOILB JUICE: 1-12 OZ CAN FROZEN (OR) !-%OZCAN CEREAL: UP TO 36 OUNCES

034 MILK:
EGGS: JUICE:

4 QTS (OR) 2-1/2 GAL ACIDOPHILUS. ENJOY, LACTAID, NUTRlSH. LACTAID 100, DAIRY EASE I DOZEN
111 OZ CANS FROZEN (OR) >M OZ CANS

~hcrl "~m=~<

... _ - - -

035 MILK: 2 QTS (OR) 1/2 GAL ACIDOPHILUS, El\.~OY, LACTAID. I\'UTRISH, LACTAID 100,
DAIRY EASE
CHEESE: UP TO I LB JUICE: 2-12 OZCANS FROZEN (OR)
2-46 OZ CA.'\'S I LB DRIED BEANSIPEAS (OR)
1802 PEANtIT BlTITER

036 NULK:
EGGS: JUICE:

2 QTS (OR) 1/2 GAL
AClDOPHILUS. ENJOY, LACTAID. NUTRISH. LACfAJD 100, DAIRY EASE CHEESE: UP TO I LB I DOZEN 1-12 OZ 0u'1 FROZEN (OR) 1-46 OZ CAN

037 MILK:

I GAL (OR) 4-12 OZCA1~S EVAP

(OR) 1-5QTBOX

JUICE: 1-12 OZ CAN FROZu~ (OR)

1-460ZOU'1

CEREAL: UP TO 24 OUNCES

I LB DRIED BEANSlPE.o\S (OR) 18

OZ PEANUT BUTrER

038 MILK:

2 GAL (OR) 8.-12 OZ C:\.:~S EVAP

(OR) 1-8 QT BOX

CHEESE: UPTOILB

JUICE: 1-12 OZCAN FROZEN (OR) 1-46 OZ

CAN

039 MILK:
EGGS: JUICE:

1 GAL (OR) 4-12 OZCANS EVAP (OR) 1-5 QT BOX I DOZEN 1-12 OZCAN FROZEN (OR) 1-460ZCAN

040 MILK: JUICE:

I GAL (OR) 4-12 OZ Ck'JS EVAP (OR) 1-5 QT BOX 1-12 OZ C....N FROZEN (OR) 1-460ZC.-'N

041 MILK: I GAL (OR) 4-12 OZ CA,"-JS YAP (OR) 1-5QTBOX
EGGS: I DOZEN JUICE: 2-12 OZ CANS FROZEN (OR)
2-460ZCANS
CEREAL: UP TO 36 OUNCES

042 CHEESE: UPTOILB
JUICE: 1-1202 CAN FROZEN (OR) 1-460ZCAN

043 CHEESE: UPTO I LB

JUICE: 1-12 OZ CAN FROZEN (OR)

1-46 OZ CAN

044 MILK:

I I LB DRIED BEANSlPE.o\S (OR) 18

OZ PEA-NUT BmlER

I

4 QTS (OR) 2-1/2 GAL

I ACIDOPHILUS, EN]O'r~ L-\CTAlD,
NUTRlSH. LACTAID 100,

DAIRY EASE

.

CHEESE: UP TO I LB

1

JUICE: ,

1-1202 c.",,! FROZE,'" (OR) 1-4<> OZc.-\1\'

I

CEREAL: UP TO 24 OUNCES

i

;

i.

5

VN - 52

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Voucher Voucher 11~~!!C

'.

Code

045 MILK 4 QTS (OR) 2-1/2 GAL. ACIOOPHILUS, ENJOY, LACTAID, NUfRISH, LACTAID 100, DAIRY EASE
CHEESE: UP TO I LB
JUICE: 1-12 OZo.." FROZEN (OR)
1-4<i OZc.....". I LB DRIED BEANSIPEAS (OR) 18 OZ PEAl\T(Jf BmTER

046 MILK: JUICE:

I GAL (OR) 4-12 OZCANS EVAP (OR) 1-5 QT BOX 1-12 OZ CA."< FROZEN (OR) !-4<iOZCAN

047 MILK: I GAL (OR) 4-12 OZCANS EVAP
(OR) 1-5 QT BOX JUICE: 1-12 OZ CA.'! FROZEN (OR)
1-4<iOZCAN CEREAL: UP TO 24 OUNCES

048 MILK: I GAL (OR) 4-12 OZ CANS EVAP

(OR) 1-5 QT BOX

EGGS: JUICE:

- I D02E.L"l'
1-120ZCAN FROZEN (OR) : 1-4<iOZCAN

CEREAL: UP TO 24 OtJ"NCES

049 JUICE: .1-12 OZ 0.." FROZEN (OR) 1-4<i OZCfIJ."
CEREId..; UP TO 18 OUNCES

050 MILK: 1 GAL (OR) 4-12 OZ CANS EVAP (OR) 2-5 QT BOXES
EGGS: 1 D02a1 JUICE: 1-12 OZCtu" FROZEN (OR)
I-4<iOZCA." . CEREAL: UP TO 36 OUNCES

051 MILK: JUICE:

2 GAL (OR) 8-12 OZ CANS EVAP (OR) 1-5 QT BOX
1-12 OZ OX FROZU" (OR) 1-4<i OZ c.~'\

052 EGGS: 1 DOZEN

JUICE:

1-12 OZc...." FROZEN (OR) 1-4<i OZ c.....".

053 MILK: 1 GAL (OR) 4-12 OZ CANS EVAP (OR) 1-5 QT BOX
CEREAL: UP TO 18 OUNCES

054 MILK: 1 GAL (OR) 4-12 OZ CANS EVAP
(OR) 1-5 QT BOX
CHEESE: UP TO I LB EGGS: 1 DOZEN JUICE: 212 OZc.~"S FROZEN (OR)
2-4<i OZ o..'\S

055 MILK: I GAL (OR) 4-12 OZ CANS EVAP (OR) 1-5 QT BOX
CHEESE: UP TO I LB EGGS: I DOZE;-';
JUICE: 1-12 OZc.~'\ FROZEN (OR) l-oMOZC.>'"

056 MILK: JUICE:

1GAL (OR) 4-12 OZ CANS EVAP (OR) 1-5 QT BOX 1-11 OZC>,.' FROZEJ,(OR) I-MOZC>,.,

._----------:-
\luucher V~uchC'r ln~~::C:

COO<

056 CEREAL: UP TO 36 OUNCES

(cont_)

I LB DRIED BEANSIPEAS (OR) 18

OZ PEfu'-'UT BUTTER

060 FORMULA: 4-1 LB CA<'\lS NUTRAMIGEN, PORTAGE.'\l (OR) PREGESTIMIL (OR) 15-13 OZ CANS ~'UTRAM1GEN (OR) 12 QTS_ ALL\1ENTUM

061 FORMULA: 4-1 LB CA<'\lS NUTRAMIGEN, PORTAGE..'\l (OR) PREGESTIMIL (OR) 16-13 OZCANS~'UTRAMlGEl\' (OR) 13 QTS. ALL\1ENTUM

062 FORMUlA: 12-32 OZCANS READY TO FEED IRON FORTIFIED El\Tf.-\,\UL (OR)
PROSOBEE NO LOW IRON FORMUlA ALLOWED

063 FORMULA: 13-32 OZeANS READYTO FEED IRON FORTIFIED El\Tf.>"\HL(OR)
PROSOBEE NO LOW IRON FOAAH:1.~ ALLOWED

064 FORMULA: 1513 OZ CANS CONCEJYfRATED IRON FORTIFIED El\'R\liL (OR)
PROSOBEE NO LOW IRON FOAA1l:1.A ALLOWED

065 FORMULA: 16-13 OZCANS CONCEJ'-.'TRATED

IRON FORTIFIED El\'FA.\liL (OR)

.

PROSOBEE NO LOW IRON FORMl,1.... ALLOWED

066 JUICE: 3-12 OZCANS FROZEt'\l (OR) 3-460ZCANS
CEREAL: UP TO 24 OUNCES

067 FORMULA: 13-32 OZ Ctu'1S READY TO FEED

IRON FOIITIFIED El\Tf...MIL (OR)

PROSOBEE

JUICE:

1-12 OZ Ctu" FROZE..l\' (OR)

I-4<iOza,\

CEREAL: UPT0240UNCES~r~'~

NO LOW IRON FOAAll1.-\ALLOWED

068 FORMULA: 16-13 OZ CANS CONCEKrRATED

IRON FOIITIFlED ENF.....\UL (OR)

PROSOBEE

JUICE:

1-12 OZCAN FROZEN (OR)

1-4<i OZ CAN

CEREAL: UP TO 24 OUNCES I1'.'BNT

NO LOW IRON FOAA1l:1.A ALLOWED

069 FORMULA: 16-13 OZ CANS CONCE.I\~RATED

IRON FOIITIFlEO ENF.:\MIL (OR)

PROSOBEE

JUICE:

I-ll OZeAN FROZEN (OR)

1-4<i OZ CAN

NO LOW IRON FORML-1.AALLOWED

070 JUICE: 3-12 OZeANS FROZEJ, (OR) 3-M OZ C-\NS
CEREAL: UP TO 36 OUNCES

071 FORMULA: 12-32 OZCANS REAm TO FEED

IRON FORTIFIED ENH.\HL (OR)

PROSOBEE

JUICE:

f-12 OZc.-\1\' FROZEl'-:(OR) l-oMOZCAN

,",0 LOW IRON FORMl1.A ALLOWED

6

VN - 53

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Vouch< Voucher mcs~~c

.....

Code

072 FORMULA: 15-B OZ CA1\1S CO:--JC8\TfRATED IRON FORTIFIED ENFAMIL (OR) PROSOBEE
JUICE: 1-12 OZ CA.'\ FROZEi'\1 (OR) 1-460ZCA.,\
NO LOW IRON FORMULA ALLOWED

073 JUICE: 2-12 OZeANS FROZEN (OR)
2-460ZeANS CEREAL: UP TO 24 OUNCES INFANT

074 FORMULA: I CAN (14 OR 16 OZ) POWDERED IRON FORTIFIED 8\TfAMIL (OR) PROSOBEE

075 FORMULA: 3-16 OZ eANS (OR) 4-14 OZ POWDERED IRON FORTlFtED ENFAMIL (OR) PROSOBEE NO LOW IRON FORM:ULAALLOWED

076 FORMUU: I CAN(t40R 160Z) POWDERED

IRONFOImFIED 8\TfAM.IL(OR)

PROSOBEE

JUICE:

2-12 OZ CAt'\1S FROZEN (OR)

2-46 OZ CA.''\S

CEREAL: UP TO 24 OUNCES L\o'FA..'JT

NO LOWIRO~ FORMULA ALLOWED

077

FORMULA:- 3CANS (l4 OR 160Z) POWDERED
. IRON FORTIFIED ENFAMIL (OR) - PROSOBEE

JUICE:

2-12 OZeANS FROZE.'\1 (OR)

2-460ZeANS

CEREAL: UP TO 24 OUNCES ll\'fA."IT

NO LOW IRON FORMULA. ALLOWED

078 FORMULA: 12-13 OZCA..\!S CONCU'TfRATED

IRON FOrmFIED 8\'F.Q1IL (OR)

PROSOBEE

JUICE:

1-12 OZ CA.'.: FROZEN (OR)

1-460ZCA..'.:

21.'0 LOW IRON FORM1JLAALLOWED

079 FORMULA: 13-13 OZ CANS COl\'CENTRATED

IRON FORTIFIED 8\TfAMIL (OR)

PROSOBEE

JUICE:

1-12 OZ eAN FROZEN (OR)

1-460ZeAN

CEREAL: UP TO 24 OUNCES

080 FORMULA: 12-32 OZ eANS READY TO FEED

IRON FORTIFIED 8\lfAMIL (OR)

PROSOBEE

JUICE:

1-12 OZ eAN FROZEN (OR)

1-460ZeAN

NO LOW IRO~ FORMULAALLOVlED

OSI FORMULA: 13-32 OZCAt\!S RADYTO FEED

IRON FORTIFIED El\'FA..\1IL (OR)

PROSOBEE

JUICE:

1-12 OZ CAt'\ FROZS'.: (OR)

1-460ZC....""

CEREAL: LlP TO 24 OUNCES f:\T.>u'tf

I

NO LOW IRO:-.1 FOR\IULA ALLOWED

II

Vuuchcrl "c"kher m~t:c
u.oc I

082 FORMULA: 15-13 OZ CANS COl\'CE.''TRATED

IRON FORTIFIED ENE-\MIL (OR)

PROSOBEE

JUICE:

1-12 OZCAN FROZEN (OR)

1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

083 FORMULA: 16-B OZCANSC02l.'CENTRATED

IRON FORTIFIED ENFAMIL (OR)

PROSOBEE

JUICE:

1-12 OZ CAN FROZEN (OR) I-4<i 02 CAN'

CEREAL: UP TO 24 OUNCES

NO LOW IRON FORMULA ALLOWED

084 FORMULA: 16-13 OZCANSCONCENTRATED

IRON FORTIFIED ENFAMIL(OR)

PROSOBEE

JUICE:

1-12 OZ CAN FROZEN (OR) 1-46 OZCAN'

CEREAL: UP TO 36 OUNCES

NO LOW IRON FORMliLAALLOWED

085 FORMULA: 5-1 LB CANS NUTRAMIGEN. PORTAGEN (OR) PREGESTL\HL (OR) 19-13
OZ CANS CONCENTRATED NUTRAMIGEN (OR)
12 QTSAUMENTUM

086 FORMULA: 19-13 OZ CANS CONCENfRATED

IRON FORTIFIED ENFAMIL (OR)

PROSOBEE

JUICE:

1-12 OZ CAN FROZEN (OR)

1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

090 FORMULA: 16-13 OZ CANS CONC8\TfRATED

IRON FORTIFIED ENFAMIL (OR)

PROSOBEE

JUICE:

1-12 OZCAN FROZEN (OR)

1-460ZCAN

CEREAL: UP TO 16 OUNCES I1\TfAl\Tf

NO LOW IRON FORM1;1.AALLOWED

091 FORMULA: 4-160ZCANS(OR)5-140Z POWDERED IRON FOImFIED ENFAM.lL(OR) PROSOBEE NO LOW IRON FORMULA ALLOWED

092 FORMULA: 13-13 OZCANS CONCEtYfRATED IRON FORTIFIED ENFAMIL (OR)
PROSOBEE NO LOW IRON FORMULA ALLOWED

093 FORMULA: 5CANS (I40R 16 OZ) POWDERED IRON FORTIFIED ENFA..\1IL (OR)
PROSOBEE NO LOW IRON FORMULA ALLOWED

094

I FORMUL-\: 15-B OZCANS CONCE.\.lRATED (OR) \ 4-16 OZCANS (OR) 5-H OZ CANS POWDER Il\TfANT LOW IRO?,

i
I I
7

VN - 54

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

\;'Udlcrj Voucher 1I\CSs.2gc 0><1<
095 FORMULA: 16-13 OZeANS CONCEl\rrRATED(OR) 4(14-16 OZ) CANS POWDER INFMrr LOW IRON
097 FORMULA: 15-13 OZeANS CONCENTRATED (OR) 4(14-160Z}CANSPOWDERIRON FORTIFIED SL\ill.AC(OR) ISOMll.., SMA (OR) NURSOY, CARNATION AlSOY NO LOW IRON FORMULA ALLOWED

098 FORMULA: 16-13 OZeANS CONCEl\rrRATED (OR) 4 (14-16 OZ) CANS POWDER IRON FORTIFIED SL\ULAC (OR) ISOMIL, SMA (OR) NURSOY, CARNATION AlSOY NO LOW IRON FORt\1ULAALLOWED

106 FORM:ULA: 15-130ZeANSCONCENTRATED(OR) 14-160Z(OR) 5-140ZCANS POWDER FORMULA WITH IRON: SIMILACIISOMIL, SMA (OR) NURSOY, GERBER, CARt"JATlON AlSOY (OR) 15-13 OZCANSCONCENrRATE(OR) 5-120Z CANS GOOD STAlIT(OR) FOLLOW-UP (OR) POWDER wrrn IRON NO LOW IRON FORt\1ULAA LLOWED

110

FORt.\1ULA:

16-130Z<;ANSCONCENTRATE(OR) 4 (14-16 OZ} CANS POWDERED FORMU-

LA WITH IRON: SIMILACIISOMIL, SMA

(OR) NURSOY, GERBER, CARNATION

ALSOY (OR) 16-13 OZCANSCONCEN-

TRATE (OR) 5(12 OZ) CANS GOOD

STAlIT(OR) FOLLOW-UP (OR) POWDER

wrrnIRON

NO LOW IROl\' FORMULA ALLOWED

157 FORt\1ULA: 15-13 OZ CANS CONCENTRATE (OR) 4(14-16 OZ) CA."JS POWDERED FORMULA wrrn: IRO~: SIMILACIISOMll.., SMA (OR) NURSOY, GERBER, CARNATION ALSOY, (OR) 15-13 OZ CANS CONCENTRATE(OR) 512 OZCANS POWDERED GOOD STAlIT wrm IRON NO LOW IRON FORMULA. ALLOWED

158 FORMULA: 16-13 OZCANS CONCENTRATE OR 4(14-

16 OZ} CANS POWDERED FORMULA

wrrn IRON: SIMILACIISOMll.., SMA (OR)

NURSOY, GERBER, CARNATION ALSOY,

(OR) 16-13 OZCANS CONCENTRATE

(OR) 5-12 OZCANS PO\VDERED GOOD

STAlIT wrrn IRON

NO LOW lROl\' FORMULAALLO'NED

I 262 FORMULA: 12-32 OZCANS READY TO FEED IRON FORTIFIED L:\CTOFREE

I

NO LOW IRO;\ FORMULA ALLOWED

263 1 FORWJL....: 13-32 OZeANS READY TO FEED IRON

I

FORTIFIED UCTOFREE

!

NO LOW IRO;\ FORMul.... ALLOWED

'()uchcr- \ -Ou<."hcr nl(.-su~c..
f::ooc
'64 FORMULA: 15-13 OZCAJ'.!SCONCG'.!TR\TED IRON FORTIFIED L-\CTOFREE NO LOW IRO", FORMULA ALLOWED

65 FORMULA: 16-130ZCANS CONCENTRATED IRON FORTIFIED L....CTOFREE NO LOW IRON FORMULA ALLOWED

67 FORMULA: 12-32 OZ CANS READYTO FEED IRON

FORTIFIED L....CTOFREE

JUlCE:

1-12 OZCA.NFROZEN (OR) !-400ZCAN

CEREAL: UP TO 24 OZ D\TfANT

NO LOW IRO:" FORMULA ALLOWED

1268 FORMULA: 16-13 OZCA."1SCONCEl\rrR...T. ED IRON

FORTIFIED LACTOFREE

JUICE:

1-12 OZCAN FROZEN (OR) 1-460ZCAN

CEREAL: UP TO 24 OZ !\TfANT

NO LOW IRON FORMULA ALLOWED

69 FORMULA: 16-13 OZCANS CONCENTRATED IRON

FORTIFIED LACTOFREE

JUICE:

1-12 OZCAN FROZEN (OR) 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

1771 FORM1J1.A: 13-32 OZCANS READY TO FEED IRON

FOImFlED LACTOFREE

JUICE:

1-12 OZCANFROZEN (OR) 1-460ZCA."l

NO LOW IRON FORMULA ALLOWED

72 FORMULA: 15-13 OZCANS CONCENTRATED IRON

FORTIFIED LACTOFREE

JUICE:

1-I20ZCAN FROZEN (OR) 1-460ZCAN

NO LOW IRON FORMULA ALLOWED

74 FORMULA: 1-140ZCANPOWDEREDIRO:-l FORTIFIED l....CTOFREE NO LOW IRON FORMULA ALLOWED

75 FORMULA: 3-140ZCANSPOVlDERED IRON
FORTIFIED LACTOFREE NO LOW IRON FORMULA ALLOWED

76 FORMULA: I-HOZCAN POWDERED IRON

FORTIFIED LACTOFREE

JUICE:

2-12 OZCANS FROZEN (OR)

2-460ZCANS

CEREAL: UP TO 24 OZ Il\TfANT

NO LOW IRON FORMULA ALLOWED

77 FORMULA: 3-14 OZ CANS PO\VDERED IRON

FORTIFIED LACTOFREE

JUICE:

2-12 OZ CANS FROZEN (OR)

2-460ZCANS

CEREAL: UP TO 24 OZ Il\'F.A.NT

NO LOWlRON FORMULA ALLOWED

m l FORMULA: 12-13 OZCANS CONCfJ\;TR-\TED IRON

FORTIFIED L....CTOFREE

-1------------ 1JUKE:

1-12 OZCANFROZEN(OR) 1-46 OZ (A,"J NO LOW IRO" FORMUL-\ ALLOWED

8

VN - 55

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Vuuchcf Voucher mcs,;;t~<: Cock

279 FORMULA: 13-13 OZ CANS CO:--:CENTR~TED IRON

FORTIFIED LACfOFREE

JUICE:

1-12 OZCAN FROZE.,\, (OR) 1-460ZCAN

CEREAL: UPT0240Z

NO LOW IRON FORMli1.A ALLOWED

280 FORMULA: 12-32 OZCANS READY TO FEED IRON

FORTIFIED LACfOFREE

JUICE:

1-12 OZ CAN FROZE.'\' (OR) 1-46 OZ CAN

NO LOW IRON FORMu1.A ALLOWED

281 FORMULA: 13-32 OZCANS READY TO FEED IRON

FORTIFIED LACfOFREE

JUICE:

1-I20ZCAN FROZE.'\' (OR) 1-460ZCAN

CEREAL: UPTO24 OZ

NO LOW IRON FORMULA ALLOWED

282 FORMULA: 15-13 OZCANS CONCENTRATED IRON

FORTIFIED LACfOFREE

JUICE:

1-12 OZCAN FROZE."\' (OR) 1-460ZCAN

NO LOW IRON FOR,\lli1.A ALLOWED

283 FORMULA: 16-13 OZ CANS CONCE.l\rrRATED IRON

FORTIFIED LACfOFREE

JUICE:

1-12 OZCA]'l FROZE., (OR) 1-460ZCAN

CEREAL: UPT0240Z

NO LQ\ IRON FOR,\fu1.A ALLOWED

284 FORMULA: 16-13 OZ CANS CONCE.VTRATED IRON

FORTIFIED LACfOFREE

JUICE:

1-12 OZCAN FROZEl-: (OR) 1-460ZCA.t~

CEREAL: UP TO 36 OZ

NO LOW IRON FOR,\lli1.A. ALLOWED

286 FORMULA: 19-13 OZCANS CONCE..'rrRATED IRON

FORTIFIED LACfOFREE

JUICE:

1-12 OZ CAN FROZE.'\' (OR) 1-46 OZ CAN

NO LOW IRON FOR,\lliLAALLOWED

290 FORMULA: 16-13 OZ CANS CONCE..'rrRATED IRON

FORTIFIED LACfOFREE

JUICE:

1-120ZCANFROZE.'\ (OR) 1-460ZCAN

CEREAL: UP TO 160ZINFAI\'T

NO LOW IRON FOR,\!l:1.AALLOWED

291 FORMULA: 514 OZ CANS POWDERED IRON FORTIFIED LACfOFREE NO LOW IRON FORMULAALLOV.'ED

292 FORMULA: 13-\3 OZ CANS CONCE..VfRATED IRON FORTIFIED LACfOFREE NO LOW IRON FORMULA ALLO\\'ED

375 FORMULA: 4-14 OZ CANS POWDERED IRON FORTIFIED L-\CTOFREE NO LOW IRON FOR:\lUL-\ ALLOWED

9
VN - 56

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Checking Out the WIC Customer

\Vhen food is purchas~d with a WIC voucher, the cashier must do the following:

1. Check the customer's WIC identification card for the proper WIC ill number and authorized person(s) signature(s). The customer is not allowed to use WIC vouchers in the store if he/she does not have the WIe ID card.

2. For m:lnual voucher(s), check to see if the voucher has been signed once by the WIC customer on the left side of the voucher (Sign Here at WIC Office).

3. Check the dates on the voucher. Vouchers can-

not be used before the "FU'St Day to Use" nor

after the "Last Day to Use" dates.

.

4. Separate the food listed on the voucher from other purchases, if the WIC customer has not done so.

5. Ring up !fte shelf price pr price on item(s) of WIC food(s) for eachvoucher. Make sure that the exact types and amounts of approved WIC foods are being purchased. Do not include sales tax.

6. Print the amount of the purchase in the "Pay Exactly" space on the voucher in the presence of the WIC customer.

7. Have the WIC customer sign the bottom right side of the voucher in the "Sign Here at Grocery Store" space after the amount is written in. After the participant has signed, compare the signature with the WIC ill card. If the customer's name does not appear on the ill card, do not accept the voucher.

8. If the WIC customer cannot sign hislher name, the WIC customer must make hislher mark on the voucher. The cashier must initial the mark as a witness to the signature. Make sure that the ID card is checked and that the WIC customer also signed the ID card with hislher mark.

IMPORTANT NOTES: Any VlIlC customer who attempts to purchase foods that are not approved or creates other problems in the store should be reported to the State or Local VlIlC Office immediately.

VlIlC participants will enter the same check-our lines as other cuscomers and must be charged the same prices as other cuscomers. However, WIC purchases are exempt from Sales Tax.
Separate checkout lines for WIC participants in retail stores are prohibited. Signs such as "WIC vouchers not allowed in this line" or "No checks, no WIC" cannot be displayed since they are considered discriminacory. However, grocers who wish to ensure that WIC participants do not enter certain lines, such as express lines, may post "Cash Only" signs in those lines.
WIC customers must not receive change from WIC voucher purchases or credit in exchange for WIC vouchers.
WIC customers may not be contacted regarding any payment problems with WIC vouchers. Contact the Local WIC clinic if a need to contact a WIC customer should arise.
Food purchased with :i WIC voucher cannot he returned for a cash refund. (Cashiers should write "WIC" on receipts given for food purchased with WIC vouchers.)
The customer may not use a WIC voucher to purchase any item not listed on the WIC voucher.
The WIC CUStomer must never be required to pay any additional cash for items purchased with WIC vouchers. A WIC voucher can not be redeemed for more than the maximum purchase price listed on the front of each voucher.
\Toucher Payment Policy
Any WIC voucher returned by the bank to the vendor because of a missing vendor stamp may be stamped and returned to the bank for payment.
Prior to deposit, if a mistake is made upon entering the price on the voucher, the incorrect p~ce should be marked through and the correct prtce written above the error along with the cashier's initials. The voucher should then be processed through the bank as a normal voucher. If the price on the voucher exceeds the maximum purchase price, it will be returned to the vendor marked "noe for resubmission." These vouchers should be sent to the Staee VlIlC Program with the Return Voucher Payment Log to be processed for- pay-

10

VN - 57

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

ment. The State WIC Office shall only reimburse vendors for vouchers at a rate of the vendor's shelf price(s) up to, but not over, the "not to exceed" maximum amount listed on the tront of each voucher. In order for vouchers to be paid, the State WIC Office mUst obtain the vendor's Federal Employer Identifier (FEl) number or Social Security Number (SSN) of the owner ifthe FEI number is unavailable.
Any WIC voucher returned by the bank to the vendor because ofa stale date will not be paid.
Voucher Payment Procedure
If a voucher has been returned to the WIC ven-
dor not paid, the vendor may submit the voucher{s) to the State WIC Office for possible payment. The correct procedures mUst be followed for the vouchers to be reviewed: The return voucher payment log (form number
3760 and/or 3761) must be completed and sent with the' original WIt voucher{s) to the State WICOffice. The vendor should maintain the last copy of the form for their records.
If a voucher{s) is approved for payment, a copy of the form, with the payment, will be forwarded to the vendor.
Ifa voucher{s) is denied payment, a copy of the fonn will be returned to the vendor with an explanation for deniaL Also, the original vouchers will accompany the form. No payment will exceed the voucher "not to exceed" maximum.
Independently owned stores should use form number 3761 and corporate owned stores should use form number 3760.
Payment on vouchers received without the form (3760 or 3761) will be delayed.
Vendor Training
Vendor training will be conducted to inform vendors .of the appropriate program policies and procedures pertaining to \VIC vendors in the following ways: 1. Initial Authorization Training:
The Local Agency will provide training upon

initaI authorization of each WIC approved store.
2. Initial Authorization Follow-Up Training:
Within sixth (60) days of authorization the Local Agency will conduct :.m on-site monitoring/training visit on each newly authorized vendor.
3. Required Subsequent Training: (Failure to attend these trainings will result in vendor contract termination.)
Store Owner/Manager who is legally responsible for the store, shall attend all scheduled training sessions for WIC vendors, of which the vendor will be notified by the Local or State Agency. (These trainings aTe required at a minimum of once per Federal Fiscal Year.) 4. SubsequentT~ining: The State Agency will conduct on-site compliance training on ""'IC vendors at a minimum of twenty-five percent" each federal fiscal year. (Sanctions will not be assessed for violations that occur during these visits.)
Compliance Performance
The performance ofevery vendor is reviewed in
at least one of the following ways:
Monitoring
All WIC vendors will be reviewed through on-
site visits. Representatives of the Local, State, or Federal agencies will monitor your store in an unannounced manner at any time the store is open for business. All records pertinent to this monitoring visit mUst be available for review by the representative ofthe agency upon request. The monitoring visit is used to review for program policies and procedures compliance, merchant training, and personal contact with the merchant.
Audits The State "WIC Office may conduct record
audits on any vendor at any 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 oHVIC food items for a period of t:wo (2) years.

II

VN - 58

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Compliance performance The performance of every vendor is monitored
carefully with computer reports on each WIC voucher transaction. Compliance investigations
shall be conducted in authorized WIC vendors
storc:s. Vendors identified for investigations will consISt of those vendors that are considered to be potentially high risk by system reports and those vendors who have been reported to the WIC Program for potentially violating program regulations. Non-poten~al hi~h risk vendors will be randomly selected for Invesogation. A minimum of twentyfive (25) percent ofWIC vendors will be investigate~ each Federal Fiscal Year. Investigators shall shop WIth \VIC Vouchers to determine whether a store is complying with WIC program requirements.
Vendors will receive Vendor Profile sheets on an
a.nnual.basis: An! vendor identified as being poten-
oally high nsk WIll be investigated by the State . WIC Office. If the vendor is found to be in viola~on o~ pr?gram policies and regulations through an I~vesogao~n;he will be assessed points for violaoons occurring in each investigative visit or will be dis~u.alified according to the points assigned. In addloon, redeemed vouchers are reviewed by the State Agency and repayment will be requested for vouchers exceeding the vendor's shelf price. Notification of investigation results will be given at the close of the district investigations.
.Vendors. not involved in a current investigation
WIll be noofied of other administrative sanction
points assessment at the time they are assigned.
Vendor agreement renewal By federal regulations, the state does not have to
renew agreements with V,TIC vendors. Any WIC vendor .wh? has not signed a vendor agreement by the explraoon date will be terminated and may reapply by submitting a vendor application. In order for a WIC vendor agreement to be renewed each.year, the vendor must meet the following reqUIrements:
1. Store must have the minimum required inventory of\N1C foods at all times. Physical inventory must be viewed by the WIC representative(s) at the time of the vendor review visiL Proof of order of food items shall not be accepted. (See page 2 for minimum requirements and pages 13 -14 for sanction point system.)
2. Store shelf prices for 'VIC food items must be

compatible with other stores in the state. This means that the prices must not exceed ten (10) percent above the state average for small stores (peer group 1 WIC vendors).
3. The store must be sanitary. The State WIC Office will work with the State Department of Agriculture sanitarians to determine the appropriateness of this criterion if it is used as a reason for disapproval or disqualification of a vendor application or agreement.
4. The store must be open for business a minimum of eight (8) hours per day, six (6) days per week.
5. The store must currently be licensed by the State Deparonent of Agriculture.
6. The store owner or manager who is legally responsible for the store shall attend all regularly scheduled required subsequent training sessions for WIC vendors, of which the vendor will be notified by the Local Agency.
Sanctions, Disqualifications, and Terminations
Any WIC vendor found to be in violation of program policy and!or regulations will be assessed a point value collSistent with the severity of the violation. (As per federal regulation 2%.12 (K) (1), the Georgia WIC Program has taken into account the severity and nature of violations in establishing the Sax:ction Point System). Each violation of program policy and!or regulations has a set point value and a specific time period during which the points will remain on the vendor's record. In addition, a ven-
dor shall be disqualified from WIC Program partic-
ipation ifdisqualified from Food Stamp Program participation or if the vendor is no longer licensed by the Department ofAgriculture.
AIl points earned are retained on the vendor file for a period of one year. Points will "roll off' one year from the date of receipt.
Disqualifications When a vendor accumulates 25 or more sanction
points, the store shall be disqualified from the VlIC program, with tlle exception of hardship cases to WIC participants or probation ofWIC vendors. This could result in disqualification from Food Stamp Program participation. The period of disqualification is determined by the nature of tlle vio-

12

VN - 59

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

lation, the number of \iolations, and past disqualifi-' cations. The actual disqualification periods are determined using the same criteria for every vendor.
Vendors will receive Vendor Profile sheets on an annual basis. Any vendor identified as potentially high risk will be investigated by the State WIC Office. If the vendor is found to be in violation of program policies and regulations through an investigation, he/she will be assessed points for violations occurring in each im'estigative visit or will be disqualified according eo the points assigned.
Vendors not involved in a current investigation will be notified of points as they are assessed or assigned.

Oli shelf near WIC food items.
6. Accepting WIC vouchers outside valid time periods.
7. Allowing WIC food items eo exceed the quantity specified on the voucher.
8. Failure to calculate (ring up) sales ofWIC purchase(s). .
9. Failure to srock the required inventory ofContracted infant formula or failure to stock me required inventory of two or more VVIC food items (types and/or brands) at first offense. (physical inventory must be viewed by a WIC Representative at the time ofvisit. Proofoforder offood items is not acceptable.)

Probation Period and Hardship Cases Ifthe manager who is legally responsible for the
operation of a 'WIC approved store is different from the manager who received the maximum amount of sanction points for disqualification, the State WIC Agency shall grant a probationary period. The Probationary Period shall be for the same period of disqualification.
A probationary period can be granted only once per authorized WIC vendor. In addition, ifdisqualifying a vendor causes hardship to WIC participants, the vendor shall be granted a probationary period. A hardship case is granted only when the nearest authorized WIC vendor is 10 miles or more away from the nearest WIC clinic. If a violation occurs within the probationary period, the vendor shall be disqualified for the full disqualification period.
The following is a description of the sanction point system and how it works.
Sanction Point System
Five (5) Point Offenses 1. Failure to check the WIC ID card at the time of
a purchase with VVIC vouchers. 2. Stocking a 'VIC food item(s) outside of manu-
facturer's not-eo-exceed date{s).
3. Failure to repay overcharges within 30 days, based upon certain computerized reports.
4. Allowing similar food items to be purchased instead ofWIC approved foods.
5. Prices not marked clearly on 'VIC food items or

Ten (10) Point Offenses 1. Failure to repay overcharges within 60 da)'$,
based upon certain computerized reports.
2. Discrimination.
3. Issuing rainchecksIIOU's.
4. Contacting WIC participants for any reason regarding a WIC transaction.
5. Failure to provide vouchers or inventory records upon request.
6. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.
7. Allowing purchase of non-similar food items in exchange for WIC vouchers.
8. Not writing price on vouchers before participant signs.
9. Allowing substitutions for food items listed on WIC vouchers. (Includes substitution ofone WIC food item for another).
10. Requiring participant to pay cash to redeem WIC vouchers.
II. Allowing the purchase ofWIC foods in unauthorized container sizes.
12. Allowing the purchase of any pasteurized milk other than the least expensive brand in the score.
13. Delivering WIC foods to WIC participants' homes except when the vendor is authorized for such delivery.
14. Delivering WIC foods to 'VIC participants in

13

VN -60

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

areas which the vendor is not authorized.
15. Failure to stock the required inventory ofContraeted infant fonnula or failure to stock the required inventory oftwo or more \VIC food items (types and/or brands) at second offense. (physical inventory must be viewed by a \VIC Representative at the time ofvisit. Proofoforder of food items is not acceptable.)
16. Failure to remain open for business at least eight hours per day, six days per week.
Fifteen (15) Point Offenses 1. Failure to stock the required inventory ofCon-
traeted infant formula or failure to stock the required inventory oftwo or more \VIC food items (types and/or brands) at third offense. (physical inventory must be viewed by a \VIC Representative at the time ofvisit. Proofof order offood items is not acceptable.)
2. Allowing the purchase of any formula other than the onespecifiedon the front of the voucher. .

ilUmber o(sallction points assessed to a vendorwill determine the period of disqualification. Disqualification from the \-VIC program may also result in disqualification from the Food Scamp Program. If a vendor is disqualified from Food Scamp Program participation the vendor shall be disqualified from WIC Program participation for the same period of time, up to three (3) years. (Refer to Food Scamp Program Federal Regulations 7CFR; Part 278.)
5 points;: 90 days disqualification
10 points = 180 days disqualification
15 points = 360 days disqualification 25 points = 540 days disqualification 60 points = 1080 days disqualification
If a vendor commits a violation within six months of reauthorization after a disqualification period, ten (10) points in addition to those earned from the violation are assigned; if after six (6) months but within one year of the reauorization date after a disqualification period, five (5) points in addition to those earned from the violation are assigned.

Twenty-five (25) Point Offenses 1. Failure to repay overcharges within 90 days,
based upon certain computerized reportS. 2. Failure to allow monitoring by \VIC representa-
tives. 3. Accepting any voucher payment(s) that should
have been redeemed by another store.
4. Intentionally providing false information on vendor records.
5. Overcharging on \VIC vouchers. (Charging for foods not received or charging in excess of shelf price(s) or item cost for foods listed on the voucher).
6. Vendor's store is no longer licensed by the State Deparunent ofAgriculture.
Sixty (60) Point Offenses 1. Providing non-food items in exchange for \VIC
vouchers.
2. Providing cash in exchange for \-VIC vouchers. All earned sanction points are retained on the
vendor file for a period of one year; points will "roll off" one year from the date of receipt. The highest

Examples:
FIRST OFFENSE - VENDOR 1: Oct. 1, 1993: Five (5) points for stocking a \VIC
food item(s) outside of manufacturer's "not-toexceed" date. Jan. 5,1994: Five (5) points for failure to repay an overcharge within thirty (30) days. Jan. 17, 1994: FIVe (5) points for stoc\cing food outside ofthe manufacturer's not to exceed date. Jan. 17, 1994:
FIVe (5) points for not marking prices clearly on WIC food items or on sheI
M.arch30,1994: Five (5) points for stocking a 'WIC food item(s) outside of manufacturer's "not-co-exceed" date. Total; 25 sanction points: After fifteen (15) days' notice (and no subsequent appeal), vendor is disqualified. 5 points = 90 days disqualification
On April 15, 1994, Vendor 1 is disqualified for a period of90 days. OnJuly 15,1994, Vendor 1 is eligible for reauthorization. However, applications are processed onJuly I for that quarter. Therefore, Vendor 1 reapplies for program participation on

14

\TN - 61

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

October I, 1994. Hislher point balance is now zero.
SECOND OFFENSE- VENDOR 1 Nov. I, 1994
FIfteen (15) points for 3l.lowing the purchase ofany formula other than the one specified on the front ofthe voucher: Since this violation occurred within six (6) months ofhis/her reauthorization date, the vendor is assigned an additional ten (10) points. After fifteen (15) days of notice (and no subsequent appeal), Vendor 1 is disqualified.
15 points =: 360 days disqualification On November 15, 1994, this vendor is disqualified. He/she may reapply for authorization on October 10,1995. Hislher point balance is now zero.
FIRST OFFENSE - VE1\TDOR 2 Dec. 1, 1993 Ten (10) poin~ for issuing rainchecks. Dec. 10, 1993 Ten (10) points for discriminating against WIC participants. Dec. 30, 1993 Ten (10) points for failure to repay an overcharge within sixty (60) days. Total: 30 points After fifteen (15) days notice (and no subsequent appeal), Vendor 2 is disqualified. 10 points =: 180 days disqualification
On]anuary 15,1993, vendor is disqualified and is eligible to reapply on]uly IS, 1994.
SECOND OFFENSE - VENDOR 2 On October 1, 1994, Vendor 2 is reauthorized. May 1,1995 Twenty-five (25) points for not allowing Local Agency representative to monitor store. After 15 days notice (and no subsequent appeal), vendor is disqualified. 25 points=540 days disqualification 10 points=:90 additional days (for violating during d1C reaud1orizaoon period)
About the \VIC Acronym and Logo
The acronym "\VIC' was registered with the U.S. Patent and Trademark Office on]anuary 1, 1991, Registration Number 1,630,468. Authority

to use the "\VIC" acronym and the logo are provided in 42 U.s.c. 1876,15 U.s.c. 1051 et seq., and 7 CFR Part 246. Therefore, this notice is to inform you that Food and Consumer Services Office of the United States Deparnnent of Agriculture reserves the right to approve any uses of the WIC acronym; and any uses that are considered inappropriate shall be discontinued.
Terminations 1. If a vendor voluntarily withdraws from \VIC
Program participation, the owner must: a. Notify the Local WIC Agency of their deci-
sion. b. Return the Vendor Stamp(s) to the Local
WIC Agency.
2. Ifa vendor decides to sell a business (store), the owner must: a. Notify the Local WIC Agency of tnmsac . tion. b. Return Vendor Sca:mp(s) to the Local WIC Agency immediately.
3. A vendor shall be tenninated from Vi'IC Program participation if the store is not licensed by t.he Georgia Deparnnent ofAgriculture.
4. A vendor shall be terminated from WIC Program participation if the store is not eligible for Food Stamp Program participation/authorization or a vendor is withdrawn from Food Stamp Program participation.
Hearing!Appeal Procedures
Vendors are entitled to a fair hearing upon disqualification from the WIC Program. Any vendor requesting a fair hearing must contact the Local Agency by telephone and contact the State WIC Office in writing within fifteen (15) days of the adverse action.
SalelPurchase ofStore or Change of Ownership
Upon the sale of a WIC authorized store and the purchase of a previous WIC authorized store, the new owner/vendor applicant shall prove iliat a legitimate bill of sale cook place by complying with the Bulk Sale Law found in the Georgia Official Code Annotated and Unannotated.

15

VN -62

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-12 cont'd

VENDOR HANDBOOK

Contract!Agreement Tennination Policy
Shelf prices (on wrc approved foods) of the
vendor must be compatible with other scores within the same district. "Compatible" means prices must not be more than 10 percent above the district average by peer groups of similar store type and/or size. Continued overpricing after cwo (2) written notifications, from the State vVIC Office, shall result in termination of the vendor's agreement thirty (30) days after the second notification. Exceptions will
be made if denial to participate is based on wrc
participant hardship.
Changing Store Location When a store moves to a new location but is still
under the same management, the Local 'IC Agency must be notified of the address change Immediately.
Where to Get More Infonnation Local WIC offices cali offer help to vendors if
questions or problems arise. Most \IC offices can be contacted through the county health depart-
ment. The State wrc Office in Atlanta can also
provide assistance. To contact the State \IC Office, phone or write to this address. (please have
your wrc vendor number available when calling or
listed when writing):
Georgia Department ofHuman Resources State WIe Office
Two Peachtree St., N.W, 8th Floor Atlanta, Georgia 30303 (404) 657-2900 or call the WIC Hot Line 1-800-228-9173
Standards for participation in the program are the same for everyone, regardless of race, color, national origin, age, sex, handicap, religious or political belief.

VN -63

GA WIC PROCEDURES MANUAL FY 196

Attachment VN-12 cont1d

VENDOR HANDBOOK

Ii~1
t&I1

DHR

GEORGIA

DEPARTHENT OF

HUMAN RESOURCes

m e S t a t e

Program Office

Two Peachtree St., N\, 8th Floor

Adanta, Georgia 30303

1-800-228-9173

Form No. 3783 (Revised 6-95)

VN -64

GA WIC PROCEDURES MANUAL FY 196

Attachment VN-13

CASHIER TRAINING PAMPHLET

Cashier Training Pamphlet
FFY '96

WIC - Special Supplemental Food Program for Women, Infants, and Children
Georgia Department of Human Resources
VN -65

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-13 cont'd

CASHIER TRAINING PAMPHLET

~ rocery store cashiers are the most impor-

, tant part of the WIC voucher redemp-

J

tion process. It is the responsibility of the cashier to make sure that the "VIC vouchers are within the proper date lim-

that a signature appears on the left side of a

lual voucher, that a WIC Program authoriza-

I seal appears on the face of the voucher(s), and

t the WIC Customer receives the cor-

:WIC food items.

We hope that the following information will

? the cashier to process WIC vouchers in the ropriate manner.

'hat is WIC?

WIC stands for Women, rnfarits, and Children. WIC provides important food to p~egnant women, infants, and young children.
WIC program participants have been examined by health professionals who detennine the need for supplemental food and nutrition education.
WIC participants receive vouchers for specified kinds of highly nutritious foods. The vouchers are redeemed by grocery stores who have signed an agreement with the State. It is very important that the WIC participant receive only the foods listed on the face of the voucher. WIC gives children a chance to grow up healthy and lead active, productive lives.

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The WIC voucher is similar to a check and ,uld be redeemed just as carefully. There are three cypes of WIC vouchers: comer generated, standard manual, and blank manuaL

1

2

VN -66

Standard Manual Voucher: Manual vouchers are processed in the same manner as computer generated vouchers. The standard manual voucher has the name, 1. D. number, and dates written or typed by the staff at the clinic.

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. Oet

tt 01 C1nt vtp..

Ib Cono I4II/'In'lOOn

f'ASI8EAIIS

Ib Oolod

\'l CloIl-.. , ...

PPt"'"99"0,~1r1rII

us> 10 IS O.

Ota Uc_ FrtO

Qg=:J

M.. _ tyet 'Of""

=S~T~WOU~~~~J~r~7Alo

(

~(fjHPjmamNYrn:ilI ' . "@

VOID VOID VOID VOID VelD VOl

If BANW J UfFl II' Cj ~ 52 S 5 ?n' j:Ob ~OOOO ?81: 00 01; 3 DOli'

Ol/U

~

:n>
'='00
.~

~

>-3
~

!Z

!:Z~

~

~
,~ 1~=
>-3

~
~
n~
l>'O ~
n0
tr:l
~
~
00
~
~
t"'l
~
..c
0'\
I
~
i
!=t
-i I
W
(')
0
!=t
0:

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-13 cont'd -

CASHIER TRAINING PAMPHLET

A

Blank Manual Voucher: The blank manual voucher has the name, 1.0.
number, and dates written or typed by the staff at the clinic. The amount of food to be received by the \VIC customer is also written or typed. Redeem only the amount of food indicated. Only one (1) number should appear in each box.

Example:

0 1. ~

Correct

02. ~Correet

D 0 Incorrect D 1 1 24 Incorrect

X's are placed in all boxes where there is no number. This helps to eliminate aI!Y possible unauthorized alterationS on the voucher(s).

Checking out the WIC Customer
When food is purchased with a WIC voucher, the cashier must do the following:
1. Check the customer's v..rrc identification card
for the proper WIC 10 number and authorized person(s) signatures. The customer is not allowed to use WIC vouchers in the store if
he/she does not have the wrc ill card.

2. For manual voucher(s), check to see if the voucher has been signed (once) by the WIC customer on the left side of the voucher (Sign Here at the WIC Office).
3. Check the dates on the voucher. Vouchers cannot be used before the "First Day to Use" and they cannot be used after the "Last Day to Use."
5

A
4. Separate the food listed on the voucher from other purchases, if the WIC customer has not done so.
5. Ring up the 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.
6. Print the amount of the purchase in the "Pay Exactly" space on the voucher in the presence of the \VIC custOmer.
7. Have the \VIC customer/proxy sign the bottom right side of the voucher in the "Sign Here at Grocery Store" space after the amount is written in. After the participant/proxy has signed, compare the signature with the WIC ill card. IT the customer's name does not appear on the 10 card, do not accept the voucher.
8. If the WIC customer cannot sign hislher name, the WIC customer must make hislher mark on the voucher. The cashier must initial the mark as a wimess to the signature. Make sure that the 10 card is checked and that the WIC customer also signed the 10 card with hislher mark.
Important Notes:
Any WIC customer who attempts to purchase foods that are not approved or creates other problems in the store should be reported to the State or Local WIC Office immediately.
v.rrc participants will enter the same check-
out lines as other customers and mus.t be
6

VN -68

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-13 cont'd

CASHIER TRAINING PAMPHLET

A

charged the same prices as other customers, not to exceed the maximum amount allowed on the vouchers. However, VVIC purchases are exempt from sales tax.

Separate checkout lines for VVIC participants
in retail stores are prohibited. Signs such as
"WIC Vouchers Not Allowed In nus Une,"
or "No Checks, No WIC" cannot be displayed since they are considered discriminatory. However, grocers who wish to ensure that WIC participants do not enter certain lines, such as express lines, may post "Cash Only" signs in those lines.

WIC customers shall no~ teceive change from WIC voucher purchases or credit in exchange for WIC vouchers.

WIC customers may not be contacted regard-
ing any payment problems with VVIC vouchers. Contact the local VVIC clinic if a need to contact a WIC customer should arise.

Food purchased with a VVIC voucher cannot
be returned for a cash refund. (Cashiers should write "WIC" on receipts given for food purchased with WIC vouchers).

The customer may not use a WIC voucher
to purchase any item not listed on the MC voucher.

The WIC customer must never be required to

pay any additional cash for items purchased

with the WIC voucher. If the items purchased

exceed the maximum amount of the voucher,

the voucher with an explanation on the return

voucher payment log, should be sent to the

State WIC Office for reimbursement (not to

exceed the maximum amount) onlv after

a deposit attempt has been made.

.

7

WICAPPROvED FOODS UST

.flOOD rrnM(BRAND oc'nl'E)

NOTAU.OWED

MILIC: ~ I Gal Siz.e ONLY WhoIc, Sl:im, 99% Fa< F_(I%).{.ov. fat Q%)
<L=~ BandONLYj

~ Inlry ~(l/~ 2 oi cQ< dy)

loo,NUTR15H.
,<

s - o ~(l2<4e-ONLJl

PoWdered(3 ccS Q<

Y)

CANNOT BUY: fboo<,:dMill:
Ilattcnnill: Goa<",Mill:

a...no. CEBEAI.::(9 0.:sc....0C'AJ-e.Caa Mix Sizd'I"J1><S) CANNOT BUY: 8 <4 0< ScNlIcr 80=

O>a:-Cona, Rice, ccWheat

<;rispyCtiac<s

~= ~~<~r-~ Foni6cd)

r~~~~flnor)

I

.

~flnor)

I

QQuu>/>o:r/1on:sralnats0a0a=tacl a.s=fb-ofol<n)or)
ToaI-<Am fbI>:s
~~~~sa.c:sONLY)
a.c.ldzr(Blod:) Colby(Blod:)
~~
Knli; DcI-= (Slic<d aa4 SiaclYWappcd)

I
1 I
I CANNOT BUY:
I SaO.hocmcIisaldc.oefdcosaoc.docsc
I~O~Pl:csfOd-t60~ 1\ny8 <4 or ScmIIcr

Pkgs

jUlCE:(lOO% USRDA VItImin C FoCcmed, 46 0.:
c...s OC' U 0.: FC'OZCIlc...sONLY) ORANGE:: l.as<~BandONLY GRAPEFRt1rr: LeUt~Band O:-'l..Y ~ WcIch'.cc.Jui<yJ.AP lE: ~

i CANNOT BUY:
I Juic:eDrillb Fresh S<p:acdJuic:e
I ~~incs
Juio::s,.;a, Sugor Added

r=~Ubclo..ty)

i
!

Stall" ShurF....

i
I

'I1lriCty M.id

i

WhitCHoasc

,

OTHJ t'!E '-'1JR : ' Pun~ di ~~

,
~

J:=J :Tropia!

EGGS:(Gn<leA~I InSiz.eONLy) La.st Expensie Band 0aIy

CANNOT BUY: My O<hcr sizclQu2.lltity

DRIED PEASIIlEANS: (I Lb Siz.e ONLY)
My Bc.nd Wnloouc FInorint'Addcd

CANNOT BUY: htyO<hcr Siz.clQu=tity

PEANUT BurrER: (18 O':J.... ONLY) Any Bnnd WnIooucJdlyorHoncySp<a<l

CANNOT BUY: AnyOthc< Siz.clQu=tity

INFANT FORMULA: !Is Listl on front ofVoucher

CANNOT BUY:
~;~TI,~Ion

INFANTCEREAL: (Dry, 8 <4lloxcs 0l'.'LY) Iloc:ch Nut, Gaber. Hciiu

w.= TUNA: (6<n.e-ONLYj

La.st EJq>c:mM: B<=d,

P>d:I

CARROTS: (I Lb Prc-SaI1 PI=ic B>gOl'<1.\) Fresh.. Whole

CANNOT BUY: ~J2,,0<~Ce=1 ,.,' Fruit Of ocmuu Added
CANl'-'OT BUY: Oil P>d:I
CANl'-'OT BUY B.lk. fro= Gnned $h,l<kd.a< S.byGrTo<s

VN - 69

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-13 cont'd

CASHIER TRAINING PAMPHLET

Georgia WIe Program
Division of Public Health Two Peachtree Street, 8th floor Adam:a, Georgia 30303 1-800-228-9173
Fonn No. 3791 (R",';sed 7-9;)

VN -70

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-14

RETVRNVOUCHERPAYMENTFORM
TO: Georgia \VIC Office Two Peachtree Street, N.W., 8th Floor Atlanta, Georgia 30303

RETURN VOUCHER PAYMENT LOG

FROM:

(Corporate Office/Store Name)

(STATE WIC OFFlCE USE ONLY) REASON NOT PAID CODE:

- - - - - - - - - - ' - - - - - - - - - - - - - - - , r Vouchers will not be paid for the following reasons:

A. Sumbitted more than 60 days from date returned from bank B. Deposited after ""Vendor Must Deposit by" date

C. Redeemed after "1..asl Day to Use" date

D. Signature of Participant missing

(City, State. Zip Code)

E. Exceeded Maximum Amount Allowed

VENDOR NUMBER

VOUCHER NUMBER

AMOUNT

..
.'

Vendor (or Representalive) Signature

(Date)

r-oml 3760 (Rev. 5195)

ROUTING: White, Ycllow. and Pink Stalc WIC Office; Gold-Vendor
VN -71

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-15

POST VENDOR TRAINING EVALUATION
GEORGIA WIe PROGRAM POST VENDOlfTRAINING EVALUATION
FORM FOR FFY '96

Page: 1 of4

WICVENDOR NUMBER STORE NAME AND NUMBER STORE REPRESENTATIVE'S NAME

DISlRlcr UNIT

TEST SCORE

_

_

.--:.

_

1.

Which of the following Juicy Juice flavors are WIC approved?

a.

Apple-grape. berry, orange punch

b.

Berry, cherry, punch, orange punch

c.

Grape. cherry, tropical, punch

2.

Juice can be p~FChase in

and

sizes only.

a.

6oz. and 12 oz.

b.

64 oz. jars and 46 oz.

c.

120z. frozen and 46-0z. can

3.

How many cans of Prosobee must be on your store shelf daily?

a.

16-13 oz. cans

b.

32-13 oz. cans

c.

77-13 oz. cans

4.

How many cans of Enfamil (with iron) must be on your store shelf daily?

a.

77-13 oz. cans

b.

138-13 oz. cans

c.

186-13 oz. cans

5.

WIC requires vendors to maintain a minimum inventory of two (2) types of infant cereal. Which of the following combinations

meet this requirement?

a.

Heinz and Gerber

b.

Beechnut and Heinz

c.

Rice and Oatmeal

Form 3795 (Rev. 6-95)

Routing: White - STATE WIC OFFICE
VN -72

Yellow - LOCAL AGENCY

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-15 cont'd

POST VENDOR TRAINING EVALUATION
WIe VENDOR NPr.m~R ----,-...:..----POST VENDOR TRAINING EVALUATION FORM FOR FFY '96 (PAGE TWO)

Page 20f4

6.

What must you do with a vouchee that is rejected by the bank?

a.

Place voucher(s) in drawee for two (2) months, then call the WIC office.

b.

Immediately send the original voucher(s) and completed voucher payment log to the SUIte WIC Office.

c.

Ask the participant to pay the amount that exceeds the voucher maximum.

7.

A WIC participant gives you a voucher that has a ~Maximum purchase price must not exceedn $7.00. The purchase only

comes to $5.50. How much change should you give to the participant?

a

$1.50

b.

$0.00

c.

Keep $1.00 and give $0.50 to the participant

8.

A WIC participant/proxy has a voucher that has the signature already written in when it is given to the cashier. What should

the cashier do?

a

Accept the voucher, because checking ID is not necessary when you know the customer.

b.

Accept the voucher if the WIC participant/proxy has the WIC ID folder with them; have the participant/proxy sign

the voucher again so that the pecson's signature maybe verified against the ID card. If the signatures match, then

it's okay to accept.

...

c.

Accept the voucher this time and advise them to contact the WIC Cleek, at the clinic where they received

their voucher, for correct procedures.

9.

If you have a problem with a WIC voucher from a WIC participant, who should you contact?

a

The WIC participant.

b.

The Local WIC Office or the State WIC Office.

c.

None of the above.

10. A WIC participant gives you a voucher that has a "maximum purchase price must not exceed" $13.00. However, the actual shelf prices for the items purchased is $15.55. What would you do?

a.

Ask the panicipant for the $2.55

b.

Write the purchase amount at or below the maximum price of $13.00.

Fonn 3795 (Rev. 6-95)

Routing: White - STATE \VIC OFHCE
VN -73

Yellow - LOCAL AGENCY

(;A WIC PROCEDURES MANUAL FY '96

Attachment VN-15 cont'd

POST VENDOR TRAINING EVALUATION

WIC VENDOR NUMBER

_

POST VENDOR TRAiNING EVALUATION

FORM FOR FFY '96 (PAGE THREE)

Page 3 of 4

II.

If your store was oUt of Kix cereal and you had Berry Berry Kix on hand. would you let a WIC participant substitute Berry

Berry Kix for the regular Kix cereal?

a.

Yes

b.

No

12.

Would you ring up WIC items with other non-WIC item purchases?

a.

Yes

b.

No

13. Can food purchased with WIC vouchers be returned for cash refund?

a.

Yes'

b.

No

14.

It is okay for a WIC participant to purchase a 16 oz. package of Kraft singles.

a.

True

b.

False

15. WIC requires a minimum inventory of sixteen (16) - one (1) pound packages of cheese in two (2) types.

a.

True

b.

False

16. The cashier(s) must not charge sales tax for WIC purchases.

a.

True

b.

False

17.

Cashiers must not accept WIC vouchers from other Stales.

a.

True

b.

False

Form 3795 (Rev. 6-95)

Routing: While - STATE WIC OFFICE
VN -74

Yellow - LOCAL AGENCY

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-15 cont'd

POST VENDOR TRAINING EVALUATION

WIC VENDOR NUMB~~---,,--,--

_

POST VENDOR TRAINING EVALUATION

FORM FOR FFY '96 (PAGE FOUR)

18. The cashier must check

w,hen processing WIC vouchers.

a.

authorized person(s) signature(s)

b.

the Participant's WIC [D number

c.

all dates

d.

a, b, and c

Page 4 of4

19. The WIC participant must sign the WIC voucher\s)

the "pay exactly" area has been completed by the cashier.

a.

before

b.

after

20. Georgia WIC voucl!ers are

in color.

a.

peach

b.

green

c.

blue and white .

Form 3795 (Re\'. 6-95)

Routing: White STATE \VIC OFFICE
VN -75

Yellow - LOCAL AGENCY

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-16

VENDOR REVIEW FORM

Georgia Department of Human Resources
Division of Public Health WIC Program
VENDOR REVIEW FORM
Vendor Name Store Owner Street Address City

~... Vendor Number

Page 1 of 4

-

District

Unit

Date Of'Visit ---f--.J

I Store Manager I County

I Zip Code

Review Type
o Pre-Approval Vis,t o New Vendor (not appi<:able as yearly visit)

0 Yearly VISit 0 Follow-Up VISit

Note: Pl'tjsicallnllenlory must be viewed by WIC representst.." at the time of visit Proof of order 01 !POd items shall not be accepted.

A. Minimum InIIenIory ReQuirements

Carrots: (Pre-sealed with tape or twist ties. plastic bags only)

1. Are there at least 4 bags of 1 lb. size carrots in stock? If no. how many bags? _ _

2. was price marked on carrots or on dairy case?
3. Oidcarrots appear fresh? It no. explain:

~-

Highest Price $

and

_ Brand of Carrots

Comments on Garrots:

Yes No
o0 o0 o0

Juice:
1. Are there at least E4 cans of 46 oz. size juice in stock? It no. how many cans? _ _
2. Are there at least 12 cans of 12 oz. size frozen juice in stock? It no. how many cans? _ _ 3. Are there 2 types each of frozen and canned juice? If no. how many? Cans _ _ Frozen _ _
4. was :>rice marked on juice or posted on the shelf/dairy case? 5. was juice within date, limit? If no. !\ow many were not? Cans _ _ Frozen _ _

Yes No
o0 o0 o0 o0 o0

Apple:
Orange: Grapelruit: Other: Dole Comments on Ju<:e:

Brand Name: FIav-o-rite Kroger lucky Leaf Seneca (Red Labell Shur F.ne Stalf Thrifty Maid WhiteHouse
Ju;ey Ju<:e
Welch's 100% Least expensive only Least expensive only Pine -Orange -Banana PineaPJ)te-o<ange Cherry Tropical Punch

Prices: 46 oz.

Prices: 12 oz. Frozen

-.

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

:,'..,' '.'t.;: . ,.;:

$

$

$

$

$

$

'.","',,:'

.';:'.',

.'

-j

Form 3774 (Rev. 4-95)

Routing' White - State WIC Off<:e Yellow - Local Agency Pink - Veneor
\TN -76

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-16 cont'd

VENDOR REVIEW FORM

Cereals; (At least two types in 12 oz. sizes)

- . .~.
'.

Vendor Number

1 Are there at least 30 boxes 0( 9 oz. lo 20 oz. size of cereal,n stock? II 00. hOw many? _ _

2 Are there at least 4 types ol WlC cerea.t in stoct? If no. how many? _ _

3. Are thereat least 2 types ol 12 oz. size boxes ot cereal in stock? If 00. how many? _ _

4. was price markedon cereal or on shelf?

was 5.

cereal w~hin date Imtit? If no, how many were nol? _ _

Hi~hest Prices

Cheerios

$

CornChex

$

Rice Chex

$

WheatChex

$

Country Corn Flakes

S

Crispy Critters

S

Kix

$

Kellogg's Corn Flakes

.,

$

Special K

$

Product 19

S

Total. Corn Flakes

$

Hantest Instant Oatmeal (Regular)

$

Jim Dandy Quick G(itS (Iron Fortifoed)

$

Minute 3 &and Instant Oatmeal Plus Oat Bran (Regular)

S

Nabisco Quick Cream 01 Wheat (Regula<l

~
$

Quake< Instant Grits (Original)

$

Ouaker Instant Oatmeal (Regular)

$

Comments on Cereat

page 2 0 14
- Yes No
00
I0 0
00
I1"0 . d 00 Size

,

I
.!

!

_ - - ----"..

!

i

i

.

Peas/Beans:
,. Are there at least 8 bags 01 16 oz. size peas/beat'lS in stock? If no. how many? _ _
2. Are there at least two types 01 peas/beans? II no. how many? _ _
3. Was price marked on peas! beans. or on shell?

Brand

Type

Comments on Peas/Beans:

Yes No
I0 0 00 00
Highest Prices
$
$

Peanut Butter: (No peanut butter/jelly combinations or Honey Spreadsl
,. Are there at least 8 jars of '8 oz. peanut butter in stock? If 00. how r:lany'
2. Are there at least two brands ol peanut butter? If no. how many? _ _

--

3. Was priCe marked on peanut butter. or on shelf?

Highest Price S

and

Comments on Peanut Butter:

Brand ol Peanut Butter

Tuna: (Least expensive brand. water packed)

'. Are there at least 8 cans ol6 oz. tuna ;nstock' II no, how many' _ _

2. Vias price marked on tuna Of 00 shelf?

Lowest Price $ .

and

Brand of Tuna

Comments on Tuna: Form 37.74 (Rev. 4-95)

Rout;og: WMe - Slate WIG Office Yellow Local Agency Pink - Vendor

VN -77

I Yes No
,0 0

Ii

0 0

0 0

Yes No 00 00

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-l6 cont'd

VENDOR REVIEW FORM

Infant Cereal: (At least one type 01 cereal must be rice) . '.

Vendor Nurnber

1 Are there at least 12 boxes 01 8 oz. size of infant cereal in stock? ft no. how many boxes? _ _

2. ts rice ce-eaJ In stock.? 3. Is there one other .type. other than rice. in stock?

4 was price marKed on cereal or on shelf?
5. Was cereal wahin current date limit? " no. how many were not? _ _

Brand and Price of Infant Cereals:

Rice (Highest Pricel

Other (Highest Pricel

Beechnut

$

'$

Gerber

$

$

Heinz

$

$

Comments on Infant Cereal:

page 3 0 f 4

-I Yes No

I0 0

I0 0

t
I

0

0

I0 0

,,; 0 0

I

Formula: (Minimum of 32 cans of contracted soybase. 138 cans of milkbase and 16 cans ollac1oFree Formula)

1. Are ll1ere 138 cans of 13 oz. concentrate milk based contracted formula witl11ron in stock? ft no. how many? _ _ 2. Are there 32 eatlS of 13 oz. concentrate soy based contracted formula with Iron in stock? If no. how many? _ _ 3. Are there 16 eatlS 01 13 oz. concentrate LacloFree contracted formula with Iron in stock? If no. how many? _ _ 4. Is formula within current date timil? Ifho. how many cans were not? _ _ 5. Was price marKed on cans or on sl1elf?

Prices: 13 Ounce

! Prices: Ready to Feed

I Yes No 00

I0 0 00

I

I
.~

0 0

0 0

Prices: PoNdered

Contraded Milk based:

Contraded Soy based:

Contraded LacloFree:

Alimentum

Nutramigen

.

Portagen

$

$

1$

$

$

I$

$

$

I
I

S

:$'(:

$

,$

S

$

$

$::..

$

$

Pregestim~
Con1ments on Formula:

~:

$

$

--

Milk: (Minimum ol 20 gals. whole milk. 2"1.. 1~ & skim milk oIlhe least expeosNe b<andl

1. Are there alleast 20 gals. of milk in stock? If no. how many? ___
2. was price marked on milk or posted on the dairy case? 3. was milk within current date limit? If no. how many were not? ___

Lowest Price: S

and

Comments on Milk:

Brand of Milk

I Yes No 00 00 00

Cheese:
, Are there at least 16 one pound packages of cheese in stock? If no. how many? _ _

2. Are there at least two types of cheese in stock? If no. how many? _ _

3. Was price marked on cheese or posted on the she"'dairy case?
4. Was Cheese within date limit? If no. how many were not? ___

Highest Prices of Cheese:
i

American

$

Monterey Jack $

Colby

$

Mozzarella $

Cheddar $

Comments on Cheese; .'

Eggs: (Least Expensive Brand)

- - 1. Are there at least 16 doz. Grade A Large eggs in stock? If no. how many?

2 V'Jas ortce marked on eggs Of posted on the dairy case?

- - 3 were eggs wtthtn date limit? If no. how man,. Ylere not?

Lov.lest Prtce: S

and (Grade A Large)

Comments on Eggs:

"orm 377.. (Rev. "-95)

Routing: White - State WIC Office Yellow Local Ageoey ?,n~ - Vendor
VN -78

! i Yes No
I0 0
!0 0
I0 0
i0 0
1
I
I

t

i Yes No

! i

0

0

I
I

0

0

!0 0 Brand of eggs i

GA WIC PROCEDURES MANUAL FY '96

Att<l..chment VN-16 cont'd

VENDOR REVIEW FORM

.~endor Nurn ber

8. ParticipantlVendor Obsentation (Not applicable for pre-apPfl1V3lr

,. wee - - were any

vOUChers on hand in the store? If Yes. were all VOUCher a nounts filLed in?

" the voucher amount is not tifled in. list the voucher number(s! in (he comments section.

2. Observed WIC participant making a purchase? " Yes. were appropriate procedures .followed? _ _
tf no. explain:
-

Comments:

C. General Questions/Observations
,. Does the store need to be referred to the Georgia Department of Agriculture for inspection?
2. Is store open for business at least 8 hours a day. 6 days a week? 3. Has discrimination been reported or obse<ved? 4. Is there a need for additional training at this time? 5. Are all price columns for foods not in store marked N.lS. (Not in Store). This answer must be yes.

Page 4 of 4

Yes No 00 00
Yes No
00 00 00 00
0a

To the best of his/her knowledge, the Retail Vendor Representative hereby agrees and covenants that

neither the vendor/owner, the vendor's manager(s), or the vendor's other employee(s) is related by blood

or marriage to any WIC representative, unless otherwise revealed in writing, upon execution of the

contract/agreemept or within the contract period. The results of this monitori':.l9 visit have been discussed

with me and I understand the violations (if applicable) that were found and the food prices listed above are

correct.

.

.

Date:

_

Signature of vendor Representative

Date:

_

P;:int Name of Vendor Representative

I have discussed all findings. any violations and training needs (if applicable) with the appropriate vendor representative.

Date:

_

Signature of WIC Representative

Date:

_

Print Name of WIC Representative

District ____________ Unit

_

Vendor Representative Comments:

_

WIC Representative Comments:

_

Form 3774 (Rev. 4-95\

Routing' White - State WIC Office Yellow - Local Agency Pink - Vendor
VN -79

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-17

VENDOR REVIEW FORM INSTRUCTIONS

DISTRICTIUNIT

Enter thei:>istrictlUnit number.

VENDOR NUMBER

Enter the number assigned to the vendor.

VENDOR NAME

Enter the name of the vendor.

DATE OFVISrr

Enter the date you visited the vendor.

STREET ADDRESS

Enter the complete street address ofthe vendor.

CITY

Enter the city in which the vendor is located.

ZIP CODE

Enter the zip code of the vendor's address.

STORE OWNER

Enter the name of the owner.

STORE MANA~ER COUNTY

Enter the name of the manager in charge.
Enter the county in whicp the vendor ii:~1J.liii.

REVIEW TYPE

Check the appropriate box to indicate what type of visit you are conducting.

FOOD PRICES

Record in areas specified, Vendor Shelf7Item Prices for foods that meet the minimum inventory requirements.

VN - 80

GA WIC PROCEDURES MA~UALFY '96

Attachment VN-17 cont'd

VENDOR REVIEW FORM INSTRUCTIONS

A. Minimum Inventory Requirements (WIC FOODS): .

1. For each food item category, check the appropriate box "Yes" or "No" to indicate if the required inventory is in stock at the time of your visit. If the inventory is not adequate, enter the exact amount of each food item found on the shelf.

Example: _Yes -lLNo

Are there at least 15 boxes of 9 oz. to 20 oz. WIC cereal in stock? # of boxes ~

2. Check prices on all WIC approved food items to make sure the prices are marked on the items, on the vendors shelves, or on the dairy cases. Check the appropriate box "Yes" or uNou on the form. If"Nou is checked, please explain in the comment section of each individual food category.

Example: _Yes X"No

\Vas price marked on cereal or shelf? Ifno, explain: Prices were not marked on three boxes of 9 oz. Cheerios.

3. Check all WIC approved food items for acceptable expiration dates. Check the appropriate box "Yes" or "No". If uNo" is checked, explain what food item has expired, how many, and the date of expiration.

Example: _Yes-lLNo

Was cereal within date limit?
If no, how many were not? ..L

Comments on Cereal: Two boxes ofKix were three weeks past the expiration date of March, 1991.

VN - 81

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-17 cont'd

VENDOR REVIEW FORM INSTRUCTIONS
B. Participant Observation
If possible, observe a WIC participant making a purchase with WIC vouchers. If all procedures were properly followed, check "Yes". If you notice a procedure that is not properly followed, check "No" and explain the abuse observed in the space provided. !fyou were not able to observe a participant while visiting a vendor, indicate that there were not any participants to observe.
Check the WIC vouchers on hand in the vendor's cash register(s). If all procedures were properly followed, check "Yes". !fyou notice a procedure that was not properly followed, check ''No" and explain in the space provided in the WIC Representative Comment Section.
.'C. General Questions/Observations
1. Check 'the store's appearance for unremoved trash, dirt on the floor or shelves, evidence ofvermin, or any other evidence of unsanitary conditions. Check "Yes" or "No" on the store's appearance. If"No" is checked, explain in the space provided in theWIC Representative Comment Section.
2. Is store open for business at least 8 hours per day, 6 days per week? Check "Yes" or "No". IfINo" is checked, include the hours the store is open.
3. Has discrimination been reported or observed? Check "Yes" or "No". If "Yes" is checked, inform the vendor of Georgia's WIC policies regarding discrimination.
4. Is there a need for additional training at this time? Check "Yes" or "No". If "yes" is checked, determine what type of training is needed,
5. Have all price columns for foods not in store been marked N.I.S. (not in store). This answer must be checked yes. Therefore, the Reviewer should double check to make certain that all price columns are completed accurately.
6. Record any additional comments that you did not have space for in the body of the form, or any observations that were made and not covered in the form, in the space provided at the bottom of the last page or you may attach additional pages if necessary.

VN -82

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-17 cont'd

VENDOR REVIEW FORM INSTRUCTIONS
D. Signatures and Vendor COIIlIl1ertts" Signature ofWIC Representative: The person who monitors the vendor should. sign the form in the space provided. Upon signing, make sure the vendor understands all findings and any violations. WIC Representative Date: The date of the WIC Representative's signature. Signature of Vendor Representative: The owner or manager should sign the form in the space provided. If they are unavmlable, obtain the signature of the person in charge.

VN -83

GA WIC PROCEDURES MANUAL FY '96

istrictlUnitIClinic:

_

ounty:

_

ate of Incident:,

_

ate Reported:

_

)lIow-up Date:

enon Filing Complaint arne: ddress:

:lone:( ) tcidentfComplaint:

INCIDENT/COMPLAINT FORM
GEORCfA DEPARTMENT OFHUMAN RESOURCES
WICPROGRAM
INCIDENT/COMPLAINT FORM

Particinant Information Name: Guardian: WIC LD. Number: DOB: Phone:(. )

Vendor Information V ~dorNcodor #: Employee Name:
Title: Phone:(

Attachment VN-18
Tvpe of Complaint Participant ( Vendor {
Local AgencylState WIC Office StaffI
Local AgencvlState WIC Information StaffName: Phone: ( )

neal Agency Resolution:

tate WIC Oft"tce ResolutionfComments:

ollow-up Report:

WO Customer Service Coordinator: ORM 3772 Revised 2195

Routing: Originial-State WIC Office, Yellow-District WIC Office, Pink-WIC Clinic

Signature:
Can Complaint be Oosed at Local Agency?
Yes[ J No[ I
Signature and Title: Date: Can Complaint be Closed at State WICOffice?
Yes[ J No[ I
Signature and Title: Date:
Date:

VN -84

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-:t~

Vendor ID: Vendor Name: Activity Date: District Unit: Vendor Type: County:

EXAMPLE
VENDOR PROFILE
*** Vendor Information ***
0482
Mom and Pop Mini-Mart
PYfj:JIQ$
51
2
116
*** Volume of Business ***

FI* Paid (Curr Mo. *): FI Paid - FY* To Date: % FI Exceed 6 Mth Avg: # FI Exceed 6 Mth.Avg: % of Tot DIU PI: % of County FI: " # FI Outside Vendor Area: % FI Outside Vendor Area:

553
:::$.:~:~.~&
lOA
52.., ..,
-'.-'
82.7 210
38.0

$ Amt Paid (Cufr Mo.): $ Amt Paid - FY To Date:

5603
~7Q.~:4

$ Amt Outside Vendor Area:

2092

-# FI Paid Last 6 Mths:

6

5

4

3

2

524

473

500

497

492

519

A 13 C1 C2 E1 E2 E3 F G H I M N 0 P Q TOT

95 98 8 0 100 '0 0 1 1 o 8 o 38 0 3 20 392

xX

X

*Note:

CUlT Mo = Current Month F.T. = Food Instrumcnt/Vouchcl"s FY = Fisc:l1 Ycar

VN - 8S

GA WIC PROCEDURES MANUAL FY '96
VENDOR APPLICATIONB(J.QK:timj] COVER LETTER ..................... HEALTH DEPARTMENT LETTERHEAD

Dear Perspective WIC Vendor (Store Owner):
Per your request, enclosed is a WIC Vendor Application 1~Ii:t111:11Im~ page application. You
must submit all of the application for processing.

The line requesting your ,Georgia Department of Agriculture number is very important. It is imperative that this number be on your application; without it, your application will not be processed. If you do not already have a number, you may call (404) 656-3632 to apply. Also, if you are purchasing a store that is currently a WIe approved store, we must receive the WIC vendor stamp from the owner before your application is processed. You must also submit a copy ofthe bill of sale.

Your completed WIC Vendor Application must be returned to me at the address below no later than

4:00 p.m. on

. After that date, a pre-approval visit will be made to your

store. The evaluation will consist of a check of the minimum inventory ofWIC items, your store's

appearance, and your shelfprices. After your store has been inspected, your application will then be

forwarded to the State WIC Office for approval or disapproval. The State WIC Office will then mail

you a letter indicating approval or denial. If approved, you will be scheduled to attend an hour

Vendor Training session; if disapproved, you may call and request another Vendor Application and

reapply for the next application period.

Your completed application should be mailed to:

t.!g Enclosed in this package is a WIC Vendor Application Im;~t and the page application.

VN -86

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-21

Store Name - - - - - - WIC Vendor Number

SANCTION:~O~SYSTEM
Georgia Department of Human Resources
WICProgram
SANCTION POINT SYSTEM

Vendor Representati""

_

District Unit

_

The following is a description of the points system and bow it works:

Five (S) Point Off=

I.

Failun: to checl: the WIC 10 card :II tbe time of a p"rchase with WIC YOUChets.

2.

Stocking a WIC food ilem(s) outside of manufactun:r's noHo-excced dalc(s).

3.

Failun: to aq>ay oven:lwges within 30 days, based upon ocnain computerized reports.

4.

Allowing similar food items to be purchased instead of WIC approved foods.

5.

Priocs lI()( marb:d c:leady on WIC food items or on shelf near WIC food ilems.

6.

Accqlling WIC vouchers outside valid time periods.

7.

A1lowingWiC food items toexcced thequanlity specified on the \'OUc:ber.

8. 9.

(,,,,= Fail..... to calcuIaIe (ring up) sales of WIC p<lrchase(s).
Failwe to Slock die Rquired incDlory of CXlIUI3ClCd infant fonoula or failulC to stock the R:quired inventO<y cC :W~ or m= ,~'rc: foo( ::':"'$

lid/or

bands) at first offense. (Physical inYcntory must be viewed by WIC Repn:scntalive at die time of visil. Proof of order of food items is lI()( accq>(able.)

Ten (10) Point OOenses

I.

Failun: to repay oven:lwges within 60 days. based upon ocnain computerized reports.

2.

Discriminalion.

3.

Issuing xainchcd:sllOU's.

4.

Contacting WlC participants for any teaSon tegarding a WIC transaCtion.

5.

Fail..... to provide \'OUc:bers or in'lCntory records upon Rquest.

6.

Refusing to "'*PI valid WIC vouc:h= from panicipants in exchange for WIC food items.

7.

Allowing jlutcbase of non-similar food ilems in exchange for WIC vouc:h=.

8.

Not writing price on vouc:h= befcxe participanl signs.

9.

Allowing substitutions for food ilems listed on WIC vouchers. (Includes substitution of one WIC food ilem for anolher.)

10.

Requiring panicipanl to pay ash to redeem WIC \'OUcbers.

II.

Allowing die p<Irchase of WlC l:oods in unauthorized container sizes.

12.

Allowing die p<Irchase of any pasteurized mill: other than die least expensi"" b<2nd in the stOIC.

13.

Delivering WIC foods 10 WIC panicipants except when the -=dor is authorized for such delivay.

14.

Delivering WlC foods to WIC panicipanlS homes in ateaS which the vendor is not authorized.

15.

Failure to stock the required in'lCnlory of conUllCted infant formula or failulC to stock the requited iQ'lCnlory of twO or more WIC food itemS (types and/or

b<2nds) at second offense. (Physical invenlory must be viewed by WIC Represeillitive at the time of visil. Proof of order of food ilems is not accq>(able.)

16.

Failure to remain open for business at least eight houlS per day, six days per wee\:..

Fifteen (IS) Point Offenses

I.

Failure to stock the requited inYelltOl)' of conUllCted infant fonnula or failwe to stock the Rquired invenlory of lWO or more WIC food items (types and/or

b<2nds) at third offense. (Physical inventory must be viewed by a WIC Representative at the time of visit. Proof of order of food items is not aoeeptable.)

2.

Allowing the pun:hase of any formula Olher than the one specified on the flOftt of the voucher.

Twenty-fi"" (25) Point OOenses

I.

Failure to n:pay oven:lwges within 90 days, based upon ocnain computerized tepOltS.

2.

FailulC to allow monitoring by WIC representatiw:s.

3.

Accepting any you<:her payment(s) that should ha"" been tedeemed by another store.

4.

Intentionally providing false infonnation on vendor reoords.

5.

OvetcbaIging on WIC youdters. (Charging for foods not received or dtarging in excess of shelf prioe(s) or item Cost for foods listed on the wuc:ber.)

6.

Vendor's stoIC is no longer licensed by lbe Stale Departmenl of Agriculture.

Sixt), (60) Poin\ Offenses

I.

Providing non-food items in exchange for \VIC vouchers.

2.

Providing ash in exchange for \VIC vouchers.

All earned sanction points arc retained on tbe vendor liIe for a period of one year; points will roll off" one year from the date of receipt. If a vendor is dis qualified from Food S\2mp Program participation the vendor shall be disqualified from WIC Program participalion for the same period of time, up to three (3) years. (Refer 10 Food Stamp Program Federal Regulatioas 7CFR; Part 278). When a vendor accumulates twenty.lhe (251 or morc sanction points, the store shall be disqualified from the WIC program. witb the exception of hardship cases to WIC participants or probalion of \VIC vendors. The highest number of sanction points assessed to a "endor will delenninc the period of disqualification (Refer to the Vendor Handbook). Disqualification {rom the WIC program may also result in disqualifICation from lbe Food Stamp I'rogram.

As per Federal RC1:ulation 246.12 (k)(11. the Georgia \'lIC Program has laken into acc<lunl lhe severily and nature of "i<llations in establishing the Saneti<ln Point System.

I have n:.ad and und-crstand th( Sanction Point Sys(cm as acknowledged lJ)' my signature listed below:

Ownerfl\1.aCl3gcr

03t<:

Local Agency Authoriz.ed Repl"'C'SCnt2ti,'c

f:."(,nn 37'9-6 (Reo.' 4-95) Routing Copies: "'hite - S\VO Yellow _ Local Ag~<y Pink - Vendor

\TN -87

nate

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22

PHARMA~YIMNDBOOK
WIC
PHARMLtCY
HANDBOOK
GEORGIA DEPARTMENT OF HUMAN REsOURCES

Georgia VVIC PrograTn
VN -88

GA WIC PROCEDURES MANUAL FY 196

Attachment VN-22 cont'd

PHARMACY H. ANDB.OOK

What is WIC?

WIC stands for W}>men. Infants. and Children. The

WIC program is funded by the U.S. Depariment of

Agriculture and is administered in Georgia by the

Department of Human Resources through state, district.

and local health offices.

WIC provides important food to pregnant women and

their infants and/or young children. Proper nutrition at the
beginning of life may help prevent serious health problems. wrc gives children a chance to grow up healthy and

lead active. productive lives. WIC program participants

have been examined by health professionals who deter-

mine the need for supplemental food and nutritional guid-

ance.

The participants receive vouchers for special kinds of

highly nutritional goods. These vouchers are redeemed by

participating grocers or pharmacies (vendors) who have
signed an agreement to follow all wrc program require-

ments.

.

The Application

Process

Step i-Completing the Application
The pharmacy must contact the Local WIC Agency in its area to obtain a vendor application.
The pharmacy owner/manager must complete the application as shown below and return it to the Local WIC Agency.

Step 2-Processing the Application
1. Upon the sale of a WIC-authorized pharmacy and the purchase of a previous WIC-authorized pharmacy, the new owner/vendor applicant shall prove that a legitimate biU of sale took place by complying with the Bulk Sale Law found in the Georgia Official Code Annotated and Unannotated.
2. Shelf prices (on WIC approved formula) of the vendor must be compatible with other pharmacies within the state. Compatible" means prices must not be more than 10 percent above the state average by peer groups (similar size and/or type of vendor).

3. Thc pharmacy must be frec from any currcnt Food Stamp Program Sanctions.
4. Thc pharmacy appearance must l:Je sanitar:y with no cvidence of general lack of cleanliness. The State WIC Office will work with the Georgia Department of Agriculture Sanitarians to determine the appropriateness of this criteria if it is used as a reason for disapproval of a vendor application.
5. The pharmacy must be open for.business at least eight hours per day, six days per week.
6. WIC food (formula) must be within current manufacturer's date limit for human consumption.
7. WIC pharmacies are only allowed to sell special formula. Pharmacies shall not sen food items such as milk., cheese. eggs. juice. cereal, peas/beans, peanut butter, tuna, carrots, and infant cereal.
8. The "\VIC" acronym or logo cannot be utilized by a pharmacy with the 'exception of documents distributed to the pharmacy by the Georgia WIC Program.
Vendor applications shall be processed once a quarter. Applications must be received at the Local WIC Agency no later than 4:00 p.m., the first working day of each quar-
ter-Gctober, January, April, and July. The Local wrc
Agency must submit the entire vendor application to the State WIC Office by the end of the first month of each
quarter.. The State wrc Office will approve or deny all
vendor applications by the 15th of the second month of each quarter. (See table below for details).
If the vendor application is approved. the State WIC Office will issue a vendor number and return the vendor stamp along with the carbon copies of the application to the Local WIC Agency. The agency will issue the stamp to the vendor and give the appropriate training. Do not accept WIC vouchers prior to training and signing the WIC Pharmacy Vendor Agreement (contract).
If a vendor application is denied, the State WIC Office will write a letter to the pharmacy explaining the reason(s) for deniaL The pharmacy can correct the reason(s) for
denial and reapply for wrc program participation. Action
will be taken on all vendor applications within forty-five (45) days from the first working day of each quarter.

WIC Vendor Application Process and Deadlines

Vendor Application Deadline I Local Agency Deadline to Submit Approved

to the Local Agency

I
1,

Vendor Applications to the State Office

October 2, 1995-4:00 p.l11.
IJanuary 2, 1996-4:00 p.m.

i, OClOber 31, 1995-4:00 p.m.
i January 3i, i996-4:00 p.l11.

!April I, } 996-4:00 p.m. _.. : Aprii 30, 1996-4:00 p.m. _._._---_.... -

iJuly 1, 1996-4'00 p.m.

July 3[,1996-4:00 p.m.

State WIC Office Deadline to Process Vendor Applications
November 15, 1995-4:00 p.m. February is. 1996-4:00 p.m. May is, [996-4:00 p.m August IS, 1996-4:00 p.m.

VN -89

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMA<1{ HANDBOOK

Step 3-Training and Signing the Agreement
Once a pharmaey has been approved. thc phannacy will be trained by the Local WIC Agency and a WIC phannacy agreement will be signed by the pharmacy owner or pharmacy manager prior to issuance of the vendor stamp
and the acceptance of wrc vouchers.
A WIC vendor is expected to comply with all requirements stated in the vendor agreement. A copy of the application for certification. pharmacy price list. and pharmacy agreement are included in this handbook.
The vendor is expected to also comply with all policies
and procedures as outlined in the WIC Pharmacy
Handbook. Any pharmacy that is denied from participation in the
program has the right to a fair hearing. A hearing must be requested within fifteen (I5) days of receipt of the denial notification. The appeal should be submitted to the address below and not the Local WIC Agency.
State wrc Office
1\vo Peachtree St., NW, 8th Floor AtJanta, Georgia 30303 (404) 657-2900 or
wrc Hotline: 1-800-228-9173

The WlC Food (FormUla) Voucher
111C vouchcr for WIC foods is a chcck and should be
redeemed just as carefully. When a voucher is properly red~med. the vendor will receive credit for the amount of 'purchase by depositing it in his/her bank account. The
vendor is responsible for any mistakes that cashiers
.make with wrc vouchers, so he/she must be sure that
they know all WIC voucher redemption requirements.
The State and Local wrc offices can assist with cashier training as needed.
A WIC vendor must accept all valid WIC vouchers. However. no voucher will be redeemed for more than the
maximum amount printed on the face of each voucher. There are three types of WIC vouchers. computer gen-
erated. standard manual. and blank manual.

computer generated voucher: AU information on this voucher is computer printed.

~

"Tcl.l

..... "8 I f 783111 ~

998 6011

PARTICIPANT

,JOHN Q

11 USI12e" 1 GEORGIA WIC PROGRAM



OEPARl1<IENT OF HUMAN RESOUftCES

YCU<:t<ER NO.
29511284

@M''''-_M_ _ _... . WJ C

_ . . - ....,_ _o u'_..,..,. -~. . -

UORGIA

)

"F'qfQUO(:t'AC2KA~GEAlCO(OO~t J~801-12VOOUl CettNESR'

COOE ["YAP

27

PlGQRAM .

fORU-8.QT 80X

.

~Ict:, 1-12 01 eMf FROZElif OR 1~6 OZ C.M

e~.t;: UP TO 36 OUNCES

l8 1

~n:o Bt:U(S'PEAS (OR) 18 OZ PMlT ISUTTER

flR8TDl.Y
1lJUSE C8nln5
nil''" ~Dl.Y TOU6E
'feNJOR.t.IST
0EP0Sn."1.Y 16JUns
S030.

0ClWM CE:Kt'C

r..:;';';:;;;1
( C"fNlWt oitlC (
I ........~-t \.._~_.J

l'QUft IWlY flEEDG SHOTS AT 2 Motm-IS,. MOtmis,
CIIIOHTHS, 1$ MOfn'HS, & 5 YEARS
.

-..oPERUSE OF 1MS . 'lDUCllEftlS SUIlJlm 1lJ
STAlE Al)falEIW. ~

~I0 10 010

YOlO VOIO

YOlO VOID

YOlO . YOlO YO~~ VOID YOlO VOl

ca aANKCOIJTH
~ II" 2GS Jr Jr leU" I:Ob 0 J, Jrb81:

00 01;3 oall'

."..

2
VN-90

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY.- ", .

HANDBOOK

~

.

Standard manual voucher: Manual vouchers are processed in the same manner as compuler generated vouch-
ers. The standard manual voucher has the name. I.D_ number and dales wrilten or typed by the staff of the clinic.

I 99 9 99t

I

'ii 1.(,JJ,2221 4

I c-j.-r I
I III
GEORGIA WIC PROGRAM
OEPARTMENTOF HUMAN RESOURCES

I
74~2"'') 21 ~~y .... 4 '- 1 - - - - 1 - - - - 1 \'EI<OO<l104UST

r. : .:-::-"::.;\
I ...,.~.... t I ..... ,....~ t l...._~:-_J

Blank Manual Y0uchers:
The blank manual voucher has the name. I.D. number, and dates written or typed by the staff at the clinic. The amount of food to be received is 'also written or typed.
Redeem only the amount of food indicated. Only one (1)
number should appear in each box. Examples:
o.1.1XJ l]J Correct l]J Incorrect

IIJ 2.

[!] Correct

o ~ Incorrect

X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alterations on the voucher(s).

~ .: ~ ""CD
I el' I 99 9 99

C, p
III

PAAtlC:FN<T

,. : '. ,.,."..
I

cere", w w , i<g"~W!

) ~~!~o (VOID VOIDy:..:;~ass:; ,"CIO Vo;J

4W<r r'9L.S2SS?ll" j:OGl.OOOO?BI: 00 O(;:i 00ll"

VN - 91

GA WIC PROCEDURES MANUALFY '96

Attachment VN-22 cont'd

Processing WlC Vouchers
After a pharmacy has signed an agreement with the WIC program, he/she will receive a WIC Vendor Identification Number and a stamp with this number. Mrer the vouchers are accepted. they must be stamped with this number in preparation for a bank deposit. The vendor should inform hislher bank before or at the time of hislher first deposit that the vouchers can be delivered through the Federal Reserve System to the Bank South of Atlanta, Georgia. Payment will be assured. prior to the deposit, if: 1. A WIC program authorization seal appears on the face
of the voucher(s).
2. An authori2.ed WIC vendor stamp appears on the face of the voucher.
3. A total amount of the purchase is entered in the presence of the customer.
4. The amount of purchase does not exceed the maximum amount printed on the face of the voucher.

4. Ring up the shelf price or price on ilem(s) of WIC foOO(s) for each voucher. Make sure lhal the exact types and amounts of approved WIC foods are being purchased. Do not include sales tax.
5. Print the amount of the purchase in the Pay Exactly" space on the voucher in the presence of the WIC customer.
6. Have the WIC customer sign the bottom right side of the voucher in the ''Sign Here at the Grocery Store" space after the amount is written in. After the participant has signed. compare the signature with the WIC ID card. If the customer's name does not appear on the ID card. do not accept the voucher.
7. If the WIC customer cannot sign hislher name, the WIC customer must make hislher mark on the 'roucher. The cashier must initial the mark as a witness to the signature. Make sure that the ID card is checked and that the WIC customer also signed the ID card with hislher mark.

5. The participant used the 'roucher in your store after the "Last Day to Use'" and or before the "FU'St Day to Use" statement on the voucher. The voucher is not valid if used before the "FuSt Day to Use" or if deposited after the "Vendor Must Deposit By" date.
6. Endorsement(s) does not appear at the bottom Ieftoomer (for manual vouchers only) and right-oomer of vouchel(s). The participant must sign the area "Sign Here at WIC Office," prior to redemption of manual vouchers and/or sign a voucher register for redemption ofoom-puter-generated 'rouchers. In addition. the area "Sign here at Grocery Store." should be obtained upon redemption of WIC food item(s).
All vouchers which do not meet these requirements will be returned unpaid to the vendor.
Checking Out the WlC Customer
When food is purchased with a WIC voucher, the cashier must do the following:
1. Check the customer's \VIC identification card for the proper WIC lD number and authorized person(s) signature(s). The customer is not allowed to use WIC vouchers in the store if he/she does not have the WIC 10 card.
2. For manual vouchers (s), check to see if the voucher has been signed (once) by the \VIC customer on the left side of the voucher (Sign Here :!( \VIC Office).
3. Check the dates on the voucher. Vouchers cannot be used before the "First Da~' to Use" nor after the "Last Day to Use" dates,

Important Notes
Any WIC C)lstomer who attempts to purchase foods that are not approved or creates other problems in the store should be reported to the State or Local WIC Office immediately.
WIC participants will enter the same check-out lines as other customers and must be charged the same prices as other customers (not to exceed the maximum amount allowed on the voucher(s). However, WIC purchases are exempt from Sales Tax.
Separate checlc-out lines for WIC participants in pharmacies are prohibited. Signs such as "VIIC vouchers not allowed in this line" or "No checks. No WIC' can-
not be displayed since they are considered discrimina-
tory. However, pharmacies who wish to ensure that WIC participants do not enter certain lines. such as express lines. may post "Cash Only" signs in those lines.
WIC customers may not receive change from WIC voucher purchases or credit in exchange for WIC vouchers.
WIC customers may not be contacted regarding any payment problems with WIC vouchers. Contact the Local WIC clinic if a need to contact a \VIC customer should arise.
Food purchased with a WIC voucher cannot be returned for :! cash refund. (Cashiers should write
"WIC' on receipts given for food purchased with wrc
vouchers).
4

VN -92

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMA~:V J:IANDBOOK

The customer may not use a WIC voucher to purchase any item not listed on the WIC voucher.
The WIC customer must never be required to pay any additional cash for items purchased with WIC vouch-
ers. A WIC voucher cannot be redeemed for more
than the maximum purchase price listed on the front of each voucher.

Payment on vouchers received without (he form will be delayed.
Compliance Performance
The performance of every vendor is reviewed in at least one of the following ways:

Voucher Payment Policy
Any WIC voucher returned by the bank to the vendor because of a missing vendor stamp may be stamped and returned to the bank for payment
Prior to deposit, if a mistake is made upon entering the price on the voucher, the incorrect price should be marked through and the correct price written above the error along with the cashier's initials. The voucher should then be processed through the bank as a normal voucher. If the price on the voucher exceeds the maximum purchase price, it will be returned to the vendor marked "not for resubmission." These vouchers should be sent to the State WIC Program with the Return Voucher Payment Log to be processed for payment. The State WIC office shall only reimburse vendors for vouchers at a rate of the vendor's shelf price(s) up to, but not over,.the "oot to exceed" maximum amount listed on the front of each voucher. In order for vouchers to be paid, the State WIC Office must obtain the vendor's Federal Employer Identifier (FEI) number or the owner's Social Security Number (SSN) if the FEI number is unavailable.
Any WIC voucher returned by the bank to the vendor because of a stale date will not be paid.
Voucher Payment Procedure
If a voucher has been returned to the WIC vendor not paid, the vendor may submit the voucher(s) to the State WIC Office for possible payment. The correct procedures must be followed for the vouchers to be reviewed:
The return voucher payment log (form number 3760) must be completed and sent with the original WIC voucher(s) to the State WIC Office.
The vendor should maintain the last copy of the form for their records.
If a voucher(s) is approved for payment, a copy of the form, with the payment. will be forwarded to the vendor.
If a voucher(s) is denied payment. a copy of the form will be returned to the vendor with an explanation for denial. Also. the original voucher will accompany the form. No payment \vill exceed the voucher "not to exceed" maximum.

Monitoring
All WIC vendors will be reviewed through on-site visits. Representatives of the Local. state, or federal agencies may monitor your pharmacy in an unannoUnced manner at any time the pharmacy is open for business. All records pertinent to this monitoring visit must be available for review by the representative of the agency upon request. The monitoring visit is used to review for program compliance, merchant training. and personal contact with the merchant.
Audits
The State WIC Office may conduct record au~its on any vendor at any time. During an audit, the vendor must supply the WlC representative with documentation of pertinent records upon request. Vendors must retain copies of aU invoices relating to the purchase ofWlC food items for a period of two (2) years.
Compliance
InvestigationNendor Profile
Compliance investigations shall be conducted in authorized WIC vendor stores or pharmacies. Vendors identified for investigation wiU consist of those vendors that are considered to be potentially high risk by system reports, and those vendors who have been reported to the WlC program for potentially violating program regulations. Non-potential high risk vendors will be randomly selected for investigation. A minimum of twenty-five (25) percent of WIC vendors will be investigated each fiscal year. Investigators shaH shop with WIC vouchers to determine whether a
store is complying with wrc program requirements.
Vendors will receive Vendor Proftle sheets on an annual basis. Any vendor identified as being potentially high
risk will be investigated by the State wrc Office. If the
vendor is found to be in violation of program policies and regulations through an investigation, he/she will be assessed points for violations occurring in each investigative visit or will be disqualified according to the poilllS

5
VN -93

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY HANDBOOK

assigned. Notification of investigation results will be given at the close of the district investi~ations.
Vendors not involved in a current i;vestigation will be notified of other adminisll"ative sanction point assessments at the time they are assigned.
Vendor Agreement Renewal
By federal regulations, the state does not have to renew agreements with WIC vendors. Any WIC vendor who has not signed a vendor agreement within 30 days after the expiration date will be terminated and may reapply by submitting a vendor application. In order for a WIC vendor agreement to be mtewed each year, the vendor must meet requirements 1-8 under The Application Process.
Sanctions, Disqualifications, and Terminations
Ally WIC vendor found to be in violation of program policy and/or regulations will be assessed a point value consistent with the severity of the violation. Each violation of program 'policy and/or regulations.has a set point value and a specific time period during which the points will remain on the vendor record. In addition, a vendor
shall be disqualified from wic Program participation if
disqualified from Food stamp Program participation. All points earned are retained on the vendor file for
a period of one year. Points will "roll off" one year from the date of receipt.
Disqualifications
When a vendor accumulates 25 or more sanction points. the vendor shall be disqualified from the WIC program. with the exception of hardship cases to WlC participants or probation of WIC vendors. This could result in disqualification from Food Stamp Program participation. The period of disqualification is determined by the nature of the violation, the number of violations, and past disqualifications. The actual disqualification periods are determined using the same criteria for every vendor. (See Compliance InvestigationlVendor Profile)
Probation Period and Hardship Cases
If the manager who is legally responsible for the operation of a WIC approved pharmacy is different from the manager who received the maximum amount of sanction points for disqualifcation. the State \VIC Agency shall grant a probationary period. The Probationary Period shall be for the same period of disqualification.
A probationary period can be granted only once per authorized WIC vendor. In addition. if disqualifying a vendor causes hardship to \VIC participants. the vendor shall be granted a proba\ionary period. A hardship case is

granted only when the nearest authorized WIC vendor is 10 miles or more away from the nearest WIC clinic. If a violation occurs within the probationary period. the vendor shall be disqualified for the full disqualification period.
The following is a descriptioin of the sanction point system and how it works. (As per federal regulation 246.12 (k) (I), the Georgia WIC Program: has taken into account the severity and nature of violations in establishing the sanction point system.)
Sanction Point System
r(Ve (5) Point Offenses
1. Failure to checl< the WIC ID card at the time ofa purchase with WIC vouchers.
2. Stocking a WIC food item(s) outside of manufacturer's not-to-exceed date(s).
3. Failure to repay oveteharges within 30 days, based upon certain computerized reports.
4. Allowing similar food items to be purchased instead of WIC approved foods.
5. Prices not marked clearly on WlC food items or on shelf near WIC food items.
6. Accepting WIC vouchers outside valid time periods.
7. Allowing WIC food items to exceed the quantity specified on the voucher.
8. Failure to calculate (ring up) sales of WIC purchase(s).
9. Failure to stock the required inventory of contracted infant formula or failure to stock the required inventory of two or more WIC food items (types and/or brands) at ftrst offense. (physical inventory must be viewed by WlC Representative at the time of visit. Proof of order of food items is not acceptable.)
Ten (10) Point Offenses
1. Failure to repay overchages within 60 days, based upon certain 5=omputeri,ed reports.
2. Discrimination.
3. Issuing rainchecks/IOUs.
4. Contacting WIC participants for any reason regarding a WIC transaction.
5. Failure to provide vouchers or inventory records upon request.
6. Refusing to accept valid \VIC vouchers from panici6

VN -94

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY HANDBOOK

pants in exchange for WIC food items.
7. Allowing, purchase of non-similar food jtems in exchange for WIC vouchers.
8. Not writing price on vouchers before participant signs.
9. Allowing substitutions for food items listed on WIC vouchers. (Includes substitution of one WIC food item for another)
10. Requiring participant to pay cash to redeem WIC vouchers.
11. Allowing the purchaseofWICfoods in unauthorized container sizes.
12. Allowing the purchase of any pasteurized milk other than the least expensive brand in the store.
13. Delivering WIC foods to WIC participants' homes except when the vendor is authorized for such delivery.
14. Delivering WIC foods to WIC participants in areas which !he vendor is not authorized.
15. Failure to stock the required 4lventory of contracted infant formula or failure to.stock the required inventory of two or more WIt food items (types and/or brands) at second offense. (Physical inventory must be viewed by WIC Representative at the time of visil Proof of order of food items is not acceptable.)
16. Failure to remain open for business at least eight hours per day six days per week.

5. Overcharging on WIC vouchers. (Charging for foods not received or charging in excess of shelf price(s) or item cost for foods listed on the voucher).
6. Vendor's store is no longer licensed by the State Department of Agriculture.
Sixty (60) Point Offenses
I. Providing non-food items in exchange for WIC vouchers.
2. Providing cash in exchange for WIC vouchers.
All earned sanction points are retained on the vendor file for a period of one year; points will "roll off" one year from the date of receipl The highest number of sanction points assessed to a vendor will detennine the period of disqualification.
= 5 points 90 days disqualification
10 points = 180 days disqualification 15 points = 360 days disqualification 25 points = 540 days disqualification 60 points = 1080 days disqualification
If a vendor commits a violation within six months of
reauthorization after a disqualification period. ten (10) points in addition to those earned from the violation are assigned; if after six (6) months but within one year of the reauthorization date after a disqualification period, five (5) points in addition to those earned from the violation are assigned.

Fifteen (15) Point Offenses
1. Failure to stock the required inventory of contracted infant formula or failure to stock the required inventory of two or more WIC food items (types and/or brands) at third offense. (physical inventory must be viewed by WIC Representative at the time of visit. Proof of order of food items is not acceptable.)
2. Allowing the purchase of any formula other than the one specified on the front of the voucher.

Terminations
1. If a vendor voluntarily withdraws from WIC program participation, the owner must:
a. Notify the Local WIC Agency of their decision.
b. Return the Vendor Stamp(s) to the Local WIC Agency.
2. If a vendor decides to sell a business. the owner must: a. Notify the Local WIC Agency of transaction. b. Return Vendor Stamp(s) to the Local WIC Agency immediately.

Twenty-Five (25) Point Offenses
1. Failure to repay overcharges within 90 days. based . upon certain computerized reports.
2. Failure to allow monitoring by WIC representatives. 3. Accepting any voucher payment(s) that should have
been redeemed by another store. 4. Intentionally providing false infomlatioll on vendor
f(~<:ords.

Hearing/Appeal Procedures
Vendors are entitled to a fair hearing upon disqualification from the WIC Program. Any vendor requesting a fair hearing must contact the Local Agency by telephone and contact the State WIC Office in writing within fifteen (IS) days of the adverse action.

7

\TN -95

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

P

H

A

R

M

A

C .~.

-Y.

H.A

N

D

B

O.

O

K

Contract!Agreement Non-Renewal Policy
Shelf prices (on \V[C-approved foods) of the vendor must be compatible with other pharmacies within the state. "Compatible" means prices must not be more than [0 percent above the state average by peer groups of simi[ar size and/or type. Continued overpricing after two (2) wriuen notifications from the State WIC Office. shall result in termination of the vendor's agreement thirty (30) days after the second notification. Exception will be made if denial to participate is based on WIC participant hardship.
Changing Phannacy location
When a pharmacy moves to a new location but is still under the same management, the Loca[ WIC Agency must be notified of the address change immediately.
Where to Get More Infonnation
Local WIC offices can offer help to vendors ifquestions or problems arise. Most WIC offices can be contacted through the county Health Department. The State WIC Office in Atlanta canalso provide assistance. To contact the State WIC Office. phone 01; write to this address (please have your WIC ven<!or'number available when calling or listed when writing):
Georgia Department of Human Resources State WIC Office
'!Wo Peachtree St., N.W.; 8th Floor Atlanta, Georgia 30303 (404) 657-2900 or call the WIC Hotline 1-800-228-9173
Starulards for participation in the program are the same for everyone. regardless of race. color, national origin.
age. sex. handicap. religious or political belief

VN -96

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 contId

PHARMACY HANDBOOK

Gcocgi.a Dcp.:annt<::nl o( Human Resources DIVISION OF PUnUC HEALTH
FOR WOMEN. INFANTS AND OHLOREN
WIC PROGRANI APPLICATION FOR VENDOR CERTIFICATION

ito.-c Name

,--

AraCodc

Tdcphonc Numba

(----l

_

ilOC'c,l..ocation

City

GA ZipCodc

_

>iailingAddrcss (If Qiffacn')

County

_

;loc,cOwnc.r

Store Ma~:cr

_

:1. Number

o<Owna's Soc. Soc. Number

-'-

_

{Federaf Emptayer Identifier) lYPEOFSTORE :lO>ain :I In<kpcndcn, :I Frandtisc :I Onlg ~u:re f"'OO<.~e of Slo<e _. ..-enge ....nnu.1 Gross Sales S i~ Sump AUlhociUlfo(l, Numbc.r

HOURS OF BUSINESS Sunday Tuesday Thursday

Mo~ayO 0:--------

Wedncsd.y

_

Friday

_

S'lucd2y

_

Number of Check-OUt Count=

_

Estimated TOI2I 'k of Food Sales ...,....

-"9".,

_

_

(A stO<"< must ~ ditiblc for Food Sump Protram ....ulboriulion 10 ~:a WICVcndor.)

o( ~nmcnl Agriculture: License: Number

_

(A sfore muSf be licensed by the Department of AgriaJlUJre to be a WIC vendor)

Business License Number

Salcs Tax Number

_

Length o/Iime business has opcr.1lcd at lhe prcscnl site

_

Yes No
a a

00 you sen bcc.c. wine.. or O(her alcoholic be:\'ccages? IUs lhe business evcr operated under another namc~ 1/ yes. whal - . !he name of lhe business'

Da

t s this .a ct\.;lngc of ownership'?

:l a

Docs this St(lfe now panicip:uc in the: Fo<.ld Sl:Jcnp Pco:;ram'?

a

a

Has Ihis SlOCe e"er ""plied for W1C? If yes. SUle when

_

a

a

H:Js this S(OfC ever rcccive:d a warning_ been suspended. disqualified. Of had a pen.ah.}' assessed .against it by

\VIC Of Food Stamps: If yes. SU.tc: when :md c.xptain

Food Pk~. 4:

Vend,... CO:it

STATE \VIC OFRCE USE O!'ILY M.:1x.

Price Appto...-cd

Deotcd

_

Food Pkg. ~

Vcndor COSt

Max

Pticc Appeoved

Denied

_

Food {"kg. ~

VcndQ~ COSt

Arc s)(c u;ccs comp<:titl\'(: ....1Ih other $t'N~S tn Sl.~tc.:?.--.

Max _ Yes __ No

Price Appco'l.'(;(1.

Dented

_

Appl1C.:1ttOI\

O:\(<:

V('udol" ~u(ubc( Assigncd

_

l ;~,-~-,~-n.-'~-~.- :-,-.~ ~ ~ -_-D~,~tc~=_-~ ~-_- -__o_=_-:~'r"~c~s~,C~d~l~'Y~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~=_-~================,=..=;<=,=.=(=2

VN -97

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY HANDBOOK

.,:- ~ S()(CN~mc
: Name o( bank wl""c WIC -ouchcrs will be deposited Oaley poduas vc. received {com Other WlC pro<lueu arc .ceci-ed (,om ~ you own C)( matU.:,e any od\Ct y;roa:ry ~(O(c:(s) I dN: stocc(s)? 0 . Yes lC yes. Ii.....me 2nd ;addr= of s<oo:.(s)

a No

*c To dM: bcsc. of a\y kno--k.d:e- .aU of d.c

3ns..US uc corrcet~ 1 unc:S<:rsuRd du(.. should nl)" $lOC'C he accqgcd as ~ \VIC ~.

( will .,bidc: by \VlC rro~r.un cc:;ulations and poItcics Meludin:;.. but nollinlitod 10 (he (ollow.a::

I.l\.ucnd Vendor Eduution:
2. Tnin employcc:s rcg:udin~ 'VtC procedures:
3. Periodical rROnitorin:; and:
me 4. AU items ift vcn60c J~ccmcrn.

I UNDERSTAND THATTHlS IS ONLY A REQUEST FOR APPROVAL AS A WIC VENOOR AND OOES NOT CONSTITUTE
APPROVA!- TO l'ARTIOl'ATE It! TIlE WIC l'ROGRAM. nIEREFCRE, 1 WILL NOT ACCEl'T ANY WIC VOUCHERS UNTIL SUOI NOTICE Of' Al'l'ROVAt liAS BEEN MADE, Il!AVE AT'l'ENDEO VENoon TRAININC.AND IIIAVE BEENISSUED A \VIC VENDOR STAMr.

Sign.2turc. Title

O.:ltc.

-

nw.s:is .... q.~~r~.PcCWfts ....'ho~tkybocl'.d~ri~~.~oltxc.col<w.~on~.t.a:c .... ~sMwCd

!;~

-ncc.~I,&oSCCC'CUl')'olA;ft<owtwfc.Y..~~o.2C02~_

Yt;$ NO

fOR LOCA I. USE ONLY

G

G

I~ till: :ra.;tIC ('~qui(J minimunl ilt,-:tt',~ (1( 'VIC .:trPC"<,vcd (oc.)(J~ in (he ~'on: dur.lt~ the Pt<-A('fWO'o=l "i~t?

Conuuc.nts:

a

a

Ib,'C YC\lJ PC(wt&~ d'C 'c:n&.K ",,Ib the: GW'g,i:t \VIC A("tf'tic.:ttion 1';ACket'?

Commcnt~:
.~,..~. J~ (ccnify thai. I hayc ,"isited thtS stOC''': 3nd do I do not recommend its appco,-at foc ~nicip;stion. If (his aprtic31ion is ftOI rccomnlCndcd foe'

approval. plc.asc cl.f"Jlain WIlY:

OISnUCT UNIT

LOCAL ACf:I'CY \VIC COORDINATOR OR Olo.'>IGNI01O

F__....\7~ (,~., (. '~I

D.>.T!;
1-.. ;:..: ::.,(:
I

VN -98

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMA,C.. .Y

H ~

A

N

D

B.O

O

K

GEORGIA W.I.C. PROGRAM
PHARMACY PRICE LIST
Please fill in the prices for all fonnulas available in your phannacy.
FORMULA TYPE
ENFAMIL WITH (RON ENFAMIL LOW IRON PROSOBEE LACTOFREE SIMlLAC WITH IRON SIMILAC LOW IRON tSOMIL ISOMtt-nF AUMENTUM NUTRAMIGEN PORTAGEN PREGESTlMIL

MODUCAL PEOIASURE 8 oz. RTF can)
PEDlASURE WITH FIBER (8 oz. RTF can)
PRODUCT 80056 REABlLAN (12.6 oz. RTF can) 3232-A
OTHER FORMULAS/SIZES:

VN - 99

REV. 7195

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY HANDBOOK

.. ~~-----..-.
~- wc..~ .....~ -
('S"(<:...... ~6lIl:tnllLl"OOO~~~ ..........IITS4.C-"'O-<.,f
PHARMACY AGREEMENT

This Pt\.atmacyJ~ ~ Cs t!UIdC by .-wj between the GeotQCa ~ 01 ~ Resou<OeS. ~ d PubW: Healh. Health OCstrid

____ .Unil

~ { ~ 1 \ C ' t ' ~ ( n : < f ' O U U \ c l o c a f ~ 6 t ' o d

~_

we (~tet ceief(ed to &S U'le VerdotJ 10 ~ ~ b' the CSGlri>uten c( soeOaI ~ bmuCa to ~

oartC:iQatU in. t~

ClOUntv<ul IN ~.,

o n This . . . . Hea_"Oi:s1ric:t~.

~

beCOme eftCCCNe

_

a r d OC'\ """'~ie

_

WlC VENOOR NUMBER

The ~ . - .... _

as .... <Ole ~ ot .... The ~ _ _ Iho LOCII #qt:ItI:( 1Rl .... Iho ...etoity 10

phOrma:y _ _ Ii> ~ lor an:! on _ oJ ll'e _lde<'t;r...s _

lot _ " " _ et caCl_.

bebw.(Signatu<e MUST be c/ _

_ J Q< ~ ....

----

---

PURPO=

...e:-

This;"O<_;olot .... - _c/~.~Iot.... e t - _ _ .. ~e>o<t_-

lhe ...

_ion fo<1h

c/

neQOCiat>le foocI "Ol be _

i

n

s

l_ as'

lor .. " ""'ll

.. pucd>ase byee ot _

et eatitehle

0ec>at1me<L

The Vendor is _

cclely lot .... _

THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT

--......

VN - 100

GA WIC PROCEDURES MANUAL FY 496

Attachment VN-22 coned

PHARMACY HANDBOOK

WfC VENOOO NUMeeR

THE PHARMACY VENOOR HRE:8Y AGREES ANO COVENANTS ItS FOU.OW'S:

A. Uoon not:ite:.ation tft)m 'he t..o<:al h:fen::r. to ~. ritia. 6me ocriod a.oc'eed 4.()OC'\ by the Ptr.atmacy &tid Chc ~ AQetcy. the t'oeGeSsaty

c.e..(lr()ty of anyone d the ~i:;IfWanf: ~~.
e That af, oriees ....4 be d::at1y cn.aric.edC'i\he< on the bod km ~ ~ . c. To ~ we ~ toe' ~ do the ~ (l( ~ diQit*e w.c Ion'nutas. In. .eddCt0c\. the ~ ~ .acceoc .aft ...~&<:l WlC

""-""'=.

o. To ac.c:ecx ('0 WI<: ~.u ~ on out orpcoesen( c:red't ~(sl.

""""""". we E. To aooeot no

~ ifOm ~ ~ ~ cftc:c VWtv <301 day.c Cn:xn ,he issuanee date OC" orioc to ts.sue 4a't $I'lOw'ft on the

F. G. HL .

part_ . ttooa"o"ccucxsoen.l.y,".",".".."."."."..".",'"""'&"""n.f.l.oGeoo<do_'a OWlfCt"""'"o<"a"m"SrEtrA_l....... _ _

"T;:o)

s_et

WICWbl'Cmu"C'a- "a t' "OC"

befow

the

n

o

r

mal' pt\aI'm ~

IeCI

qy

ia:IIde

'_ cxioe. b

_ tl( not te

l.

e.a.o-o.e0ed

cne muimucn

etnOtInf.1~ 0 _

on.

th..e..t.IO. l~ .oChet.

,he

......

ClClU<teSY g;..., 10 _~ ..............

~. To ~ oIinlo<mat'on"",,_ Oft WIC _ _

K.

oTor

_ clftc:l

_ __...

~ ,...(110-.

. .

,..,.,...... __

0<0Qt sed<

~ >m oc>e<aI_ioensw. "t"C"i"c1>0o!thUe

lf.

oacta_l

f"t-O'<:l"cr>. pUat

1:

liObpra!nhlse.

.S..t.anleo.t!

b

e

~

CC>nCO'Mo

lhl:se

L To _ _ no _

"'_bdweenlhe.,natmacy -ewt~'-plaQe duMa. WlCwu::nec-..

.... To _ _ no _ _ or ~ d. &nf -.c:tw:< fat coslI, aediC.....-. cIom<>s. ~ or _

lonn<Aa: ~' -

is not ~ '"""lliW'IlCt OC<lOC<<ngClO<QOn$. _or""""""",, - . ~.. 1

cuI>.

N. To ot<ain at !he lime '" ....,..... "" 0t9na< custome< ~ Oft !he WlC _ _ and ""lU<Sl!he ~ b ........ woe O"Cifca"'"

c~ anfb.d.

o..oaes

lcih gneedO"<l I-i.

.d we - . . ~.the

.

can

be

~

Ilhe _ _ is _

to <tow. we itSeccali:lctcald be1<irQ u.. ......

WlC fatlhe _ _ ...

..ouc:he<as~

u.o 0.
P.

'Ii> -..en.
To.CWl-cl

in .... the 011

0d _

u"I"l'IJcotof\tec

I the WIC _ _

_ I-

.

1

0

<OCftWlhl-eclWC_ lC ""_ """"

'" b

f y

ace Ihd

til
~

time c( pun::Rase ~J belore

in lhe 1>"''''''' "'".. ......,..,.... ~ in the bani: _ 10 ~

01

WlC ~ in limely _ . ~ _

" ' - ' (15) clays c( ftldemplCn but _ _ INn ciJ;ty (GO) clays _ ... clale cI

is.suat'ce _ 0<1 lhe -.c:he< Iooe.

0. 1. OOdislrillulebaA~"""'-lin!he_cWlC~~aI_.....,;...s_!heLocaf" ~ b lhe ~'c _ _ "lhe WlC Po>v<-. OOlnoWc:t c:esItCn. and a I _ ~"""'-Iin ... _ _ WlC 1'logrant"",C:C>a<i:lctcl k~ _ _ _ lhe_~C(WlC _

2.

lbe_<WlbeOOOllll<ll2lllelora:t"""'cI~Ctthe_c(_or~ol

_

RS..

T'.o

abTidheatbrl

chtel

lSectaa le

n #qed <"C~f mday.de-n.y.

S _

t

a

l

e

a.m. Lthoeco_l

~ lor _ an_da loocl l _~

as

_olrnmlayhcelemwoleldl_ 'twlomr a...c ,...y...~..

aloudy

made onimotcoer ~



2. To _ _ .... Stat. ~ ....... lhirty (301 clays cI _ _ fat _ _ c>U:l br the Stale #qe<"Cf on woe ~ too6

b ~oco=_ tthe_""""' .... _lhe_cheIlllricec(_

T. 00 aIbw

d. "'" Local. Stat. or Fede<>I " - to

the \Ie<'do<'c ~ in an ~

at .,., 1_

the ohotmaey is .,..., lor _ s s . M. ft:COOjs ~ .. this ~ _ be made . . . . - lor ....... bt "'" - . lNe '" the

agency.

U. That _

......,. ....... oo>oe<tY 0< "'" ~le c( Geo<'Qia and ClIol caC:l _ _ .... be ft:luml b .... woe PIoQ<"'" """""'lefy <.<>on

_;""~disQualiCeat""'~ Mlhd<awol_P"'ll'UI ~ v. 1. That ... _ _ '" the _ _ _ s ) wi! not _ _ WlC ~ or _

Y/lC - . _ woe """""""-..

~ 'at tne ~unless:

a. Nctil'edin wt"itin; by.a heatth ~~iYe.

-eo b. lbe _ _ is.~awoe~ile<lt(cl_io----.lelyce4'ngcut~_we""'"""-

2. That any CUl-ot...... _

.... be ~ _ _ am "'Illaced,.;u, _

tN.I t.a.e ~ claI<s

de "'" .=<d

W.

the That

period of

~ er.oedcd U$4QC. ~ ""'" ...........

FNS

PloQ<3tn

_

be cIisQuali!"oed _

~ in the WlC f'<oo<2m lor ......... _

'"

....... uo 10 ...... 131 Y9".

X. A Vendor who c:ommCts fQiu::l or .ab.rse the pcogcam is Gab'e 10 0C'0'eCUti:x1 un:Set ~ ~ state Of be2l1aws.. lhose who

..... ",",~uIy _ . _

'" " ...........Iy oll<ain<d WlC funcls _ be eubje<:t 10 _ rone d "'" ~ It>an S '0.000. '" _

b" no< ~ than f~ (51 yeatS. or both.

y To no(~y the t...oc::a.l J.qeney ol d\a1'QeS tn ~ 0( when the Vendor ceases ooetatx'l OC" ~~ <:hat'Qe$. Tt\C$ ~~ is nul

and "'0<1 if ~ Charqes

we l State ()( ~ 0( l.oaf Sa'es laKes wilt t'Q( be coKeded on. formula items purd\aSed wiU\

~.

AA. 'to Qeda(c Chat neither the <rendQ</owner. 'he ~ s tn.anage((s.I. or the ~'s Olhef' ~$J G edited by blOOc:: or m:itTGQe \()

we 2nf

c.oon ~s-entatM:.~ss OC~Csc ~ied ., W'riting.

~ of the ~ / ~0( ..-rtM tto\.e <'C)n(r.o oenod. (soacc

~ on ~ Itvee ot. INs CQn(t'aet ~emen( foe' dCscbSlJC'e 0( rdatNes).

AS 10 .....S4Oty Cl\s.otay the ....e~'-.c..s stOtC n.arroe 01'\ the outside d. the storoe butldtn;/tacihtV. ~C 10 abOde by U'~ uS Patent .and T(aoe~l1( Laws. whid\ ~ una~iz.cd use 0( the W1C acronym a~ lO9O (I'\!:~~ 1<1 ~ration

NVi"t'1()ef> 1.630.468. CX..'-oec 1I"'l.:2U.SC 15:'6. 15US.C. lOS 1 d. SC'(l. aad 7 CFR Part 246).

VN - 101

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY HANDBOOK

WfC VENOOR NuM8R

1>"9< 3 of J

O<l add<es$ 0( C'ClalM: ..... _ _ G<O<'QQ WI<: Program 0( ~ by tile Geotgia W1C Progr :

p",;,. ~(offioet. (L_ _. L

-=-

_

(Ple.ue OllaCh addiIClnoI _ s l ~ ~sa<Y1

lL THE LOCoU. AGENCY HREBY AGREES ....0 COVE....HtS AS RlU.OWS:

A.
B. Co

-<oone<\lty.,.,. To_ u...
To ~ ... _

we u... will

_ l o t "'-...(j{ ... ~ _ t o _ s W I C ~

_.5o;t 0( - .

_10

Proocam llQtti:Oonls _10 _ _os lo t....

" " " - LiI:l os they oc:cur.

_lNle<iol To~

abOut ..... WlC ~ 10 u..._.

o. To-WlC~_""""in _ _ (I{WlC-...s.

_

E. F.

_.1 To ........ tNt an _ _ 0( IlCO*Y siQnoIure is .Good 10 art( manual wuc:t>e<c>rio< lo t'CleasinO ... -.c:fte< to< _On.

To ~ ... _ _ COI;1f cl 0I'f~. in _ _ <K...., 01 ~ _ art( cl\ol'OOS in "'" _

..., SCale ReQoIat......

~~lh.e.~. ,:.;...~10"- u... -

- . COI;1f (j{ art( WlC cegulatOn<sl <K poGoy

afttc.; the Vendot's

G. H.

To assist ... _

-.0I'f""""" -c.;

_ T o ~ " ' _ " " , , ~

1_ 0 lhe w.e

Progc.....

III 80TH PARTIES AGREE ANO COVENANT AS FOLLOWS:

A. That no """5d 0( n-et ....... ~ ''''' _ _ u...l.o<:oI ~ (See 5ec:t;o"l.. AB.I.

s.

aoe. Not ~ ~ br teasoc'I5 01

C".aoe,. CObr. cex. national origin.ot~.

Co The _

Ns u... right 10 ........ ant _ . . . - by the Lac:oI ~ affec:linQ the Ve<-do<'s _ y to oartOc>ale in "'" W1C "'-"'"

Ul"de< the te<ms (I{ 1Ns~.

.

D. The _

_be (I{ INs ~ is lon~ Ol\ lhe ~ _ . New ~

executed each \"'....

E. This ~ _ be<:ome

..,., in ils _ y . - . _ changes 01............., 01 PNtmacy.

F. This~....,.beca~...,_ ...<ty-etW1yl3Oldayl:wri.--.

_s "'" CO<"GI_ . """"" f'Cfat"""""" G. In "'" _
H. That _

cl _ _ '" """"..., .... I~ _ 1 0 .... State ~ lor .... WIC Plogo-am.1Ns #q'ee<ne<lI _ 1 - - . . , . "

... Locall>qe<>cy ""' .... _

..... anGllGgaoioft 10 _ _ Veftdor~.

l. This ~/CO<'Uacl

0( 0<0(>erty intec'est. The

between ''''' Local _

an:! the _

ends ~ the exQC;I(;on date of tf'\i:s ~/COtlltaet.

"". SAHCTlONS me APl'EAL PROCEOISRES:

A SANCtl<lWS
Ven::ioc's auG be disQuaWoec lrom V/IC Program o.attic:::iPateon for a perOd of c.IO to (tvee (3) yeatS if vOat4ons 0C0If CSuc..n; a (:OITl()I&anee 0Ut'd'&ase. monitorino YCsi( by ;a v~ reoresentat..-e. or Food Stamp Pro;<3m partc~On.. Proc:educ'es Coc' ~ the s.anc:t~ a4"e Ol,lI(Cined tn the W'C Ptwmacy Hanaboo'c. Any ~ CSCsQuaCCted f4'om. WfC ~tion may be dCsQu.ata"-ed fCOCTl Food SlamQ ~m. oat1ieio:atton
~e"to7CFR21a

8 APPEAL PAOCEOUllE
Vendo<'s ace entilUeo \0 ~ I c'" ~~tor.; ~ o.SQYau<:.atoion t~ the we Prc:>o<"a.m. Arty ~ roeQueSC:~ .a t~ he.arinj) ""U$! COtQct tf'e
Local AQeney by te'eohone . .3t'C: conwc:. ttIC: State \"/1CCWtce .n-""'ing wiCnin flte~ ('5) days attec the ad,'on ~ is be'"o UItet\.
TRMINATtOt.l POLICIES

A \l.ct'OOt' st\aSl t>e tet"'ot\at~o If()r."l VII(: ~am Datt<;.ioat,ion d ttlc ~ Cs NOr lOcC('1scd by the ~ Oeoart~ oC ~c~. 8 A V~ $l'\al be te("",f"\3~c hOt"\ wtC PtoQtam oanco..at)C'\ if IhoeS1Of~~noc ~t>Ce (Of Food ~amo Pn)()I'am o.a~~tO'l/acAhOnJ:aC<Yl
oc .a Vcnoot cs wft"Otawn l,<"""" ~OOC' S:c~ P'Oo:/tam (\art~I<OO

;;;0.;1.'.'"

VN - 102

GA WIC PROCEDURES MANUAL FY '96

Attachment VN-22 cont'd

PHARMACY HANDBOOK

,I. J:~.\;J.;f;'n;"
::~rtl
DHR CEORCIA DEPARTMENT OF HUMAN RESOURCES
State WIC Program Office
Two Peachtree Sr., SW; 8th Floor Atlanta, Georgia 30303
1-800-228-9173
Fan" No. JS09 (Rev. 5/95)
VN - 103

TABLE OF CONTENTS

I. Authorization of Foods II. Prescribing Foods, General . _. __ .. _ _
;;
~! C. Food Packages .. .
D. Documentation Required III. Infants ....

_

_ __ .. __ .. _

_..

Page FP-l .. FP-l

. _ FP-3 _... __ . _ FP-3
.. FP-4

B. Infants a Through 3 Months.
C. Infants 4 Through 12 Months

.. _ FP-6 FP-9

B. Food Package Assignment

_

..... _ FP-12

C. Standard Manual Food Package

_

.. _

~i

V. Children I to 5 Years

.. _. _. ___ __. ...

. . __ .. _.

_.... FP-12 . . _. _. FP-15

A. Tailoring _.

.

. _.. _. __ .

. __ . _

FP-15

B. Food Package Assignment. _. . __

FP-15

C. Standard Manual Food Package. . . . . . . . . . . . . . . . . . . . . . . . . . .

FP-15

m .U;g_lnmEilil.t;;lA1!lif~t.~ ilt1E_t.i.~r'_ltl1l.t:~

VI. Pregnant and Breastfeeding Women

FP-16

A. Tailoring

FP-16

B. Food Package Assignment

_. _.. FP-17

C. Standard Manual Food Package

_. __

FP-17

VII. Postpartum, Non-Breastfeeding Women

A. Tailoring

__ . _

B. Food Package Assignment

.

FP-18

FP-18

FP-19

1ttJ!f.Ii~~.~~_fl.&.1i(l'i:~1lIWfjw. .~t{Mfmt.1~ II E~B.'~f1fiUfd;:~\1j'klWJfMiI _111*.%.lIt_ifaI1
I~ mt~1inr.I_~~f@~;%1~~~~1t.~~iti~h_'1~.'1Ijlmfmtllj~iiltlaltlt
!Ii.!
!i?!
fit

Attachments:

FP-l Infant Food Packages, Formula Types, Sizes and

Maximum Monthly Amounts ...

FP-25

~g~ m1~ ~gjm.j1.m~lifitl~~ifQi$;ff.l9~tlf;~qi.ii~~ii

B r.i.~~lf.~~11#.!I!1:t4.fjfirlj![tocij!@j~liq~1~I~fl.fitT{&f*{.[llflfl+~ iRill .EII,9.R~jl~.~r.t~~i!ftti!~~lW}1%i(l~nAi~)l~~BlI'I!I.4,1F~.tl!~!

m!~ ~Illmt{Wl~~Dl~?(~D!!\,f{~r.;f#r;mflt~fJjlRql~lf~#.?tlt.!~g'.t}R:;~f.'*@lijg~~

i.i_ FP-IO Women's and Children's Packages, Prescription Maximum Amounts

FP-41

I t . ;;;. f_~1IIl.I:lr4iJlY.; 11.IJm!1TI7.tlif.~

tlli~

~1~_1IIl~.~\.

E.~_

t;Nf~ ~

m!;1~ ~t".I~f~~m;4.~!t;rt'l[.I,~\B~

FP-14 Children's Food Packages, Maximum Monthly Amounts

FP-52

FP-15 Children's Food Packages

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FP-53

Eifftl! ll.t!j!!~~lF~li~lr!!'~~!I[qf,fjR~!4f~i~l::mmig!f;Irt'~

FMilfl
FP-18
EBilQ

~f~!J.~11~~lf~t~g~~m~i!qm~j~!;j:!!~iJ.j!;;%t.\,J!Jj:l;;;!1'li~w11ll111j:WR1i~~

Women's Food Packages, Maximum MontWy Amount

FP-59

FP-22 Postpartum, Non-Breastfeeding Women's Food Packages, Maximum Monthly Amounts .

. .. FP-68

FP-26 Georgia WlC Special Formula Referral Form

.

Hiligi ~m@j~~.19'Y~!Fgg!Jl.1I1!Gnin~~Il?~#m~~

FP-73

FP-28
1t~2 !I~g
FMjIj
mr~.g

Georgia WlC Approved Foods

FP-77

. 1 ~f\l[&I_RI@.l~114#tW%11It.f}Wffljjgf~jm1itttl*.liiillIlg.t]
i~tmll9m!IJ}_.:l{tlB[i!t~r~J%i41K;{JI:!JIIJt4~&1jMlgjgilr@ljwilm.lliJf;;liIl,i)

I I I I I I I I I I I I I I I I I I I I I I I

GA WIC PROCEDURES MANUAL FFY '96

L AUfHORIZAnON OF FOODS

The State food package tailoring policy is:
A competent professional authority (CPA) * shall prescribe types of
supplementalfoods and the food package in quantities appropriatefor each participant, taking into consideration the participant's age and dietary needs. The amounts ofsupplementalfoods may equal but shall not exceed the maximum quantities specified in this section.

There will be NO deviation from the State food package tailoring policy.

* A CPA is a nutritionist, registered dietitian, registered or licensed practical
nurse, physician, physician's assistant, or other certified health official that has been trained by the State or local agency.
n. PRESCRIBING FOODS. GENERAL

A. Contract Versus Non-Contract Formula

The State of Georgia has entered into a three (3) year contract (January 1, 1995 -December 31, 1997) with Mead Johnson Nutritional Group to provide formula for WIC participants. All infants participatin in the Georgia WIC Program will be provided with vouchers for a contract formula (iron fortified Enfamil or Prosobee.)

.

he contract currently provides the following

rebate on each can of iron fortified Enfamil,Prosobee:@~ ~plll1

purchased:

Concentrate: Powdered: Ready-To-Feed

When Mead Johnson's wholesale formula price increases, the amount of Georgia's rebate increases cent for cent beginning the month in which the increase goes into effect.

FP - I

GA WIC PROCEDURES MANUAL FFY '96

the WIC Program may provide the infant with vouchers which specifY the physician prescribed, formula. Refer to page FP7-9 for information regarding the documentation required for prescription formulas.

B. Food Groups

There are six (6) food groups authorized by Federal WIC Regulations. Each ofthe groups are specified according to age and/or condition. The groups are:

Food Group from the Federal WIC Regulations

Age/Condition

Computer Food Package Series Number

Infants 0 Through 3 Months

111,112,113,121,123,
133,134,143,193,216,
222, 223, 299, g~t~!~:Q~! 999

II

Infants 4 Through 12

111,114,115,116,117,

Months

118, 126, 131, 136, 137,

146,196,217,221,224,

225,299,

III

Children/Women with

Special Dietary Needs

381,383,382,999

IV

Children I to 5 Years

600-607 999

V

Pregnant and

Breastfeeding Women 401, !fill; 999

VI

Postpartum, Non-

Breastfeeding Women

VII

Exclusively Breast-

feeding Women

408,

999

FP - 2

GA WIC PROCEDURES MANUAL FFY '96
C. Food Packages
Food Packages translate'the foods authorized in each food group into varying quantities within the maximum amounts allowed. See Attachments
~f!~1~gi~f!l1:~'f1~;~B~$i!1~!!~~fggj
I. Tailoring. Food packages are designed to meet individual participants' nutritional needs and food preferences. Available computer food packages include maximum amounts of food allowed, reduced amounts and/or the elimination of specific food items. Any food grouping that includes allowed foods within the maximum amounts
mA.tal~Ya.cbhe:~Plernetssc:jnBb3eiigd:;lf~:B!,i:J1jgtjlj~;gi;j~;!j?f~@;.$j3fj g;!j?igij; list
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.
2. Assignment of Food Package Number. The CPA assigns the computer food package number that coincides with the quantity/items desired. If a computer food pakage is unable to meet the needs of the . participant, the CPA specifies the quantities/items desired and assigns a food package 999. A.food package 999 includes any allowed food combination not available as a computer package.
3. Assignment Method. The CPA must evaluate and assign food packages:
a At each WIC assessment/certification.
b. When medically necessary. c. At the request of the participant.
D. Documentation Required
I. General Documentation
a. During the WIC assessment/certification, the CPA must write the food package number in the "Food Package" space provided on the WIC Assessment/Certification Form. Also, docl)ment
FP - 3

GA WIC PROCEDURES MANUAL FFY '96

specific tailoring instructions for food package 999 in the "Comments" section or in the progress note of participant's health record.

b. Between WIC assessments/certifications, the CPA must document food package changes in the "Comments" section provided on the WIC Assessment/Certification Form. Date and sign (including title) any changes. The use ofa signature stamp is not acceptable.

2. Additional Documentation. Additional documentation is required for:

a.
b. c.
d.
e.
Ii. m. INFANTS

soy or special formulas (e.g. as indicated for chronic diseases or medical conditions) Ready-to-feed formula Lactose intolerant women and children requiring more than two (2) pounds of cheese per month Low iron formulas (e.g. as indicated for conditions such as hemochromatosis, etc.) Hospital based formula ~~t;~.!i~gl?~

Food Group I is for infants 0 through 3 months of age and consists only of ironfortified formula. Food Group II is for infants 4 through 12 months of age and consists of iron fortified formula, iron-fortified cereal and juice.

A. Tailoring
1. Breastfed Infants. The best food for the normal infant is breastmilk. Until the maternal milk supply is well established at 4-6 weeks of lactation, no formula should be offered. Infant formula should not be provided, through food package assignment or free samples, to breastfeeding participants who do not want or need it. Breastfeeding is defined as feeding a mother's breastmilk to her infant(s) at least once a day. If a mother chooses to both breastfeed and formula feed her infant, powdered formula is recommended. However, liquid concentrated formula is available. The maximum amount offurmula
FP - 4

GA WIC PROCEDURES MANUAL FFY '96 may be assigned to breastfed infants by the CPA. The need for the maximum allowance must be thoroughly documented in the infant's health record.
2. Formula Fed Infants. When the participant is not breastfeeding, iron-fortified formula is the recommended formula for healthy infants. The definition of iron-fortified formula is: A completeformula not requiring the addition ofany ingredients other than water prior to being served in a liquid state, and which contains at least ten (10) milligrams ofiron per liter offormula at standard dilution which supplies sixty-seven (67) kilocalories per one-hundred (100) milliliters; i.e. approximately twenty (20) kilocalories per fluid ounce offormula at standard dilution.
may be authorized when a physician determines that the infant has a medical condition/diagnosis which contraindicates the use of standard iron-fortified infant formula. These conditions/diagnosis include, but are not limited to, preterm infant, metabolic disorders, inborn errors of metabolism, gastrointestinal disorders, malabso tion syndrome, aller ies and hematological disorders. .
w-calorie formulas are not authorized solely for the purpose of managing the body weight of infants. Formulas designed for parenteral infusion are not authorized for distribution by the WIC Program.
FP - 5

GA WIC PROCEDURES MANUAL FFY '96
The amount offormula required (including calorie and protein needs) is based on the infant's total body weight. Infants require approximately fifty (50) calories per pound of body weight. A general recommendation is to provide 2 Y, ounces of iron-fortified formula per pound ofbody weight, or 5.5 ounces per kilogram of body weight, when formula is the only source of calories.
The Office of Nutrition, Nutrition Guidelines for Practice recommend the introduction of solid foods when the infant is 5-6 months of age and is developmentally ready. For maximum formula amounts, see Attachment FP-l. The adjusted age is to be used with premature infants.
3. Cereal. Cereal is not authorized for the infant 0-3 months of age. The Office of Nutrition, Nutrition Guidelines for Practice recommend that cereal be introduced when the infant is 5-6 months of age and developmentally ready. A maximum of twenty-four (24) ounces of cereal per month is authorized.
4. Juice. Juice is not authorized for the infant 0-3 months of age. The Office of Nutrition, Nutrition Guidelines for Practice recommend that juice not be offered until the infant can drink from a cup to help prevent "nursing bottle caries". A maximum of ninety-two (92) fluid ounces of single strength juice per month is authorized.
B. Infants 0 Through 3 Months
Food Group I consists only offormula. No cereal or juice is authorized for this food group.
I. Food Package Assignment. The food packages for infants 0 throu 3 months of a e are listed on Attachments FP-3, FP-4 and FP-5.

a. No formula: 299

b.

i Contract

'formula:

Jj~~ilrn~itlg$kg:l:~~gl:[~~.

m
~

FP - 6

GA WIC PROCEDURES MANUAL FFY '96

e. Non-contract special fonnula: 111, 133, and 999

2. Standard Manual Food Package. The CPA will assign a food package to the participant upon certification and enter the food package number on the WIC/Assessment/Certification Fonn. The standard manual food package for infants (food package JJ3) will be issued for all infants until the computer vouchers for the assigned food package are generated. The CPA may require the assigned food package be given to the participant. The CPA must state this in the "Comments" section of the WIC Assessment/ Certification Fonn. The actual assigned food package must then be issued instead of the standard manual.

3. Additional Documentation. Additional documentation is required in

the participant's health record whenever medical conditions/diagnosis

warrant a change from the contract standard fonnula to a non-contract

soy formula or special formula (contract or non-contract), contract or

non-contract

hospital based fonnula, ready to feed

fonnula 9Hjg~i![gti[~im;ig!i~\

a. Contract or Non-contract Special fonnulaINon-contract soy fonnula.

(I) All changes from the contract standard fonnula to a (contract or non-contract) formula must be written on either a prescription pad, private physician office letterhead or district/county letterhead or the Georgia WIC Formula Referral Fonn stating the name of the alternative fonnula and the m.lt.~~R~;~1!l~~m~~. Orders must have an original signature ofthe physician or licensed/certified health professional working under standing order. Prescription pads with preprinted or prestamped non-contract formula orders will not be
accepted.

(2) A physician's written or verbal order is required prior to food packa e ass' When a written order is not present, confinnation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.

FP -7

GA WIC PROCEDURES MANUAL FFY '96

(3) A current order is required every three (3) months; including at initial and subsequent certification, mid-certification nutritional assessment, and with any change in the order.

(4) Certified Nurse Practitioners, certified Nurse Midwives, or certified Nurse Specialist working under public health Nurse Protocol, may order a special formula (excluding Low Iron and Hospital based formulas). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.

(5) A Registered or Licensed Dietitian following the Department of Human Resources Protocol on Infant Formula Intolerance may:

(a) Recommend to a physician/certified nurse practitioner/ midwife/specialist a suitable alternative formula, or

(b) Refer a participant to a physician/certified nurse practitioner/ midwife/specialist for evaluation.

b. Hospital based Formula.

(I) A physician's written or verbal order is required prior to

food packa e assi

'

A current order is

required at least every three (3) months.

(2) Orders must be written on either a prescription pad, a private physician's letterhead or district/county letterhead or Georgia WIC Formula Referral Form stating the name ofthe formula, the diagnosis (physical condition) and the expiration date of the order.

c. Ready-to-feed formula.

(I) The CPA must document in the participant's health record that there is an unsanitary or restricted water sURply, poor

FP - 8

GA WIC PROCEDURES MANUAL FFY '96 refiigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
C. Infants 4 Through 12 Months Food Group II consists of formula, iron-fortified cereal, and juice. I. Food Package Assignment. The food packages for infants 4 through 12 months of age are listed on Attachments FP-2, FP-3, FP-4, FP-5. The use of the contract standard formula is required unless a special formula (contract or non-contract) is prescribed by appropriate providers. The food package numbers are: a. No formula: 221 and 299 b. Contractm~Iformula: 115,116,117,118,126,217,221, 224, 225 and 999 c. Non-contract so formula: 146 196
I
e. 2. Standard Manual Food Package. The CPA will assign a food package
upon certification and the computer food package number which matches the assigned food package will be given to the participant. The standard manual food package for infants is food package 113. The standard manual will be issued for all infants until the computer vouchers for the assigned food package are generated. The CPA may
FP - 9

GA WIC PROCEDURES MANUAL FFY '96
require the assigned food package to be given to the participant at the time of certification. The CPA must state this in the "Comments" section ofthe WIC Assessment! Certification Form. The actual assigned food package must then be issued instead of the standard manual.
3. Additional Documentation. Additional documentation is required in the participant's health record whenever medical conditions warrant a change from contract standard formula to a non-contract soy formula
or special formula (con;;t,traljc~tl~o:!rrln~ojMn~-~c~o:~n~!tjr\a~c.t), hospital based formula,
ready-to-feed formula !f
a. Contract or Non-Contract Special FormulaINon-Contract Sov Formula.
(I) All changes from the contract standard formula to a (contract or non-contract) formula must be written on either a prescription pad, private physician office letterhead or district!county letterhead or the Georgia WIC Formula Referral Form stating the name of the alternative formula and the !i~~WJilill.Wi!?I:~!~iii. Orders must have an original signature of the physician or a licensed/certified health professional working under physician's authority. Prescription pads with preprinted or prestamped non-contract formula orders will not be accepted.
(2) A physician's written or verbal order is required rior to food package assignment en a written order is not present, confirmation ofa verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
(3) A current order is required every three (3) months; including at initial and subsequent certification, mid-certification nutritional assessment, and with any change in the order.
(4) Certified Nurse Practitioners, certified Nurse Mid-wives, or certified Nurse Specialist working under public health Nurse Protocol, may order a contract or non-cont~act
FP - 10

GA WIC PROCEDURES MANUAL FFY '96
special formula (excluding Low Iron and Hospital based formulas). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.
(5) Registered or Licensed Dietitians following the Department of Human Resources Protocol on Infant Formula Intolerance may:
(a) Recommend to a physician/certified nurse practitioner/ midwife/specialist a suitable alternative formula, or
(b) Refer a participant to a physician/certified nurse practitioner/midwife/specialist for evaluation.
b. Hospital based Formula.
(1) A physician's written or verbal,'io;Jr~de~r@ii;is~r,~e!q~uii~rediif!Priotro
food package assignment' f1; A current order is required
at least every three (3) months.
(2) Order must be written on either a prescription pad or a private physician's office letterhead or district/county letterhead pc the Georgia WIC Formula Referral Form stating the name of the formula, the diagnosis (physical condition) and the expiration date of the order.
c. Ready-to-feed formula.
The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
FP - 11

GA WIC PROCEDURES MANUAL FFY '96
IV. CHILDRENIWOMEN WITH SPECIAL DIETARY NEEDS Food Group III consists offonnula, iron-fortified cereal, and single strength juice. A. Tailoring Due to the varying ages and conditions, tailoring for this package must be carefully individualized. I. Formula.
Also, Formula may not be authorized solely for the purpose of enhancing nutrient intake or managing body weight of children and women participants. The WIC Program does not prohibit the use of authorized fonnulas for tube fed individuals. ~@t~}1@f!IDj!@Y@g!f4B~&glm#~~ll.t!wg!f~Q; 2. Cereal. A maximum of thirty-six (36) ounces of cereal per month is authorized. 3. Juice. A maximum of one hundred thirty-eight (138) ounces of single strength juice per month is authorized. B. Food Package Assignment The food packages for children and women with special dietary needs are listed on Attachment FP-ll. The food package nlimbers are 311, 312, 313,
~~'~[!I~~~jl~~~i;~~;~I~;11t~~~29~~3,:;~~~~~~;:,!!:;!!!~~!~~;:~
well as amounts for cereal and juice are included in Attachment FP-5. C. Standard Manual Food Package
FP -12

GA WIC PROCEDURES MANUAL FFY '96
There is no standard manualfood packagefor Food Group IlL
D. Additional Documentation. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from the contract standard formula to a non-contract soy formula or special formula, (contract or non-contract), hospital based formula, ready-tofeed formulal.lttQW1tQn(q~A
1. Contract or Non-contract Special FormulaINon-contract Soy Formula (a) All changes from the contract standard formula to a (contract or non-contract) formula must be written on either a prescription pad or private physician office letterhead or district/county letterhead or the Georgia WIC Formula Referral Form
the name of the alternative formula and the m~ii;t1~@;!,~M!4!!Jqijl
A prescription expiration date is also recommended. Orders must have an original signature of the physician or a licensed/certified health professional working under an MD's orders. Prescription pads with preprinted or prestamped noncontract formula orders wilinot be accepted.
(b) A physician's written or verbal order is required prior to food package assignment j,;,j.~~j;mE~tmlfiw,ijID ~\1!ng!1!M:(Q~~J When a written order is not present, confirmation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
(C) A current order is required every three (3) months; including at initial and subsequent certification, and with any change in the order.
2. Certified Nurse Practitioners, certified Nurse Midwives, or certified Nurse Specialist working under public health Nurse Protocol, may order a special formula (excluding Low Iron and Hospital based formulas). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation ofa verbal order must be documented in the participant's health record.
3. Registered or Licensed Dietitians following the Department of Human Resources Protocol on Infant Feeding Problems may:
a. Recommend to a physician/certified nurse practitioner/ midwife! specialist a suitable alternative formula, or
FP - 13

GA WIC PROCEDURES MANUAL FFY '96
b. Refer a participant to a physician/certified nurse practitioner/ midwife/specialist for evaluation.
4. Hospital based formula a. A physician's written or verbal order is required prior to food
'ii~it&i~iien~~!!~~:~~:~~!~~!~:~rythree
(3) months. b. Orders must be written on either a prescription pad, a private
physician's letterhead or district/county letterhead or the Georgia WIC Formula Referral Form stating the name of the formula, the diagnosis (physical condition) and the expiration date of the order. S. Ready-to-feed Formula. The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
7. Additional Formula. The need for additional formula above the maximum must be documented by the CPA in the participant's health record. See Attachment FP-IO for maximum formula amounts.
FP - 14

GA WIC PROCEDURES MANUAL FFY '96
V. CHILDREN 1 TO 5 YEARS
Food Group IV is for children I to 5 years of age. This food group consists of milk, cheese, cereal, juice, eggs and dried beans/peas or peanut butter.
A. Tailoring
General nutrient requirements for children vary with age, nutritional risk, and stage of development. From ages 1 to 3, nutrient requirements are about half those of adults with the exception of vitamin C, calcium, and iron. The requirements for these nutrients are approximately the same. It is important that an adequate food package be prescribed for the child's individual needs. This applies even where there are two (2) or more family members participating on the WIC Program.
I. Increased Need. Very active, rapidly growing and/or underweight children need more nutrients for energy, and optimum physical and mental growth and development. Chronic diseases and!or repeated infections also increase requirements. To meet the nutrient needs of these children, food packages containing the larger amounts offoods are recommended.
2. Decreased Need. The very young child or the inactive child may not require the maximum amounts offoods allowed, therefore a food package containing reduced amounts offood may be prescribed.
3. Modified Food Packages. A tailored food package may be created by the CPA to include modified foods, i.e. lower fat cheese, lowfat milk, etc.
B. Food Package Assignment
The food packages for children ages 1 to 5 years are listed on Attachment FP-lS. The food package numbers are 600-607 and 999. Refer to Attachment FP-14 for the maximum amounts of each food item allowed per month.
C. Standard Manual Food Package
The CPA will assign a food package upon certification and the computer food package number which matches the assigned food package will be given to the participant. The standard manual food package for children is
FP - 15

GA WIC PROCEDURES MANUAL FFY '96
food package603. The standard manual will be issued for all children until the computer vouchers for the assigned food package are generated. The CPA may require the assigned food package be given to the participant at the time of certification. The CPA must state this in the "Comments" section of the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual.
D. Additional Documentation is required:
I. When a diagnosis of chronic renal disease, cerebral palsy, cardiac disease, cystic fibrosis, thyroid disorders, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients is made which requires a therapeutic diet.
A current prescription from a physician is required prior to issuance of a special food package.
2. When clieese is increased to greater than two (2) pounds per month. Additional cheese may be issued on an individual basis in cases of lactose intolerance, provided the need is documented in the participant's health record by the CPA.
3. When a food package is tailored by the CPA to give less food than listed in the minimum food package !!1t~J!~lland/orto modify the type oHood (i.e. lowfat milk) given to the participant.
VL PREGNANT AND BREASTFEEDING WOMEN
Food Group V consists of milk, cheese, cerea~ juice, eggs and dried beans/peas or peanut butter.
Food Group VII consists of milk, cheese, cereal, juice, eggs and dried beans/peas, peanut butter, tuna and carrots. Limited use to exclusively breastfeeding women only.
A. Tailoring
Increased nutrient requirements due to pregnancy and lactation determine the importance of assuring an adequate food package for the participant.
FP - 16

GA WIC PROCEDURES MANUAL FFY '96
1. Increased Need. The pregnant adolescent has dual demands for nutrients for both her developing body and her developing fetus. The underweight pregnant or lactating woman also has increased nutrient needs. Pregnant adolescents, underweight prenatal women, and lactating women need the maximum amount ofthe allowed foods they will consume.
2. Decreased need. The need for protein, energy, calcium, and other nutrients are the same for the overweight prenatal woman as for the normal weight prenatal woman.
3. Modified Food Packages. A tailored food package may be created by the CPA to include modified foods, i.e. lower fat cheese, lowfat milk, etc.
B. Food Package Assignment
The food packages for prenatal and breastfeeding women are listed on Attachment FP-19. The food package numbers are 401-408 and 999. Food package 408 may be assigned to all women who are exclusively breastfeeding infants who do not receive any infant formula from the WIC program. Ifat any time the mother request formula supplementation, the CPA should change the food package of the mother and infant to reflect the change in their status. Refer to Attachment FP-18 for the authorized foods and the maximum amounts allowed per month.
C. Standard Manual Food Package
The CPA will assign a food package upon certification and the computer food package number that matches the assigned food package will be given to the participant. The standard manual food package for prenatal and breastfeeding women is food package 404. The standard manual will be issued for all prenatal and breastfeeding women until the computer vouchers for the assigned food package are generated. The CPA may require the assigned food package be given to the participant at the time of certification. The CPA must state this in the "Comments" section of the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual.
D. Additional Documentation is required:
I. When a diagnosis of chronic renal disease, cerebral palsy, cardiac
FP - 17

GA WIC PROCEDURES MANUAL FFY '96
disease, cystic fibrosis, thyroid disorders, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients is made which r uires a thera utic diet.

A current prescription from a physician is required prior to issuance of a special food package.

2. When cheese is increased to greater than two (2) pounds per month. Additional cheese may be issued on an individual basis in cases of lactose intolerance, provided the need is documented in the participant's health record by the CPA.

3. When a food package is tailored the CPA to give less food than

listed in a minimum food package

and/or to modify the type

of food (i.e. lowfat milk) given to the participant.

VIT. POSTPARTUM, NON-BREASTFEEDING WOMEN
Food Group VI consists of milk, cheese, cer~l, juice, and eggs.
A. Tailoring
Generally, this group of participants does not have the increased nutrient needs of the prenatal and breastfeeding women. Therefore, the maximum amounts allowed for each food group are reduced.
1. Increased Need. Adolescents have a higher need for calcium than the adult woman. Caloric needs may also be higher, thus the maximum amounts are recommended. Underweight women may also need the maximum amounts offoods allowed.
2. Decreased Need. The inactive individual may not require the
maximum amount offood allowed, therefore it food package
containing reduced amounts offood may be prescribed.
3. Modified Food Packages. A tailored food package may be designed by the CPA to include modified foods, i.e. lower fat cheese, lowfat milk, etc.

FP - 18

GA WIC PROCEDURES MANUAL FFY '96 B. Food Package Assignment The food packages for postpartum, non-breastfeeding women are listed on Attachment FP-23. The food package numbers are 501~!m and 999. A postpartum, non-breastfeeding food package must be issued to the participant no later than six (6) weeks postpartum. Refer to Attachment FP-22 for the foods and maximum amounts allowed. C. Additional Documentation is required: 1. When a diagnosis of chronic renal disease, cerebral palsy, cardiac disease, cystic fibrosis, thyroid disorders, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients is made which requires a therapeutic diet.
A current prescription from a physician is required prior to issuance of a special food package. 2. When cheese is increased to greater than two (2) pounds per month. Additional cheese may be issued on an individual basis in cases of lactose intolerance, provided the need is documented in the participant's health record by the CPA. 3. When a food package is tailored by the CPA to give less food than listed in the minimum food package ti~j:l,q!l and/or to modifY the type offood (i.e. lowfat cheese) given to a participant.
FP - 19

GA WIC PROCEDURES MANUAL FFY '96
Ii !lIB~1PfitlIlfit.ml
~ID ~~~~tIDI~g*mttq!i ~
FP - 20

GA WIC PROCEDURES MANUAL FFY '96 FP - 21

GA WIC PROCEDURES MANUAL FFY '96 FP - 22

GA WIC PROCEDURES MANUAL FFY '96 ~~ ;u.lI4Ii.ltf!klli\r~\\'~
m
; Pf~ghMit'lWiaBiMit~ti'~~diiigSBffi@; ~j
FP - 23

GA WIC PROCEDURES MANUAL FFY '96 FP-24

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-l

INFANT FOOD PACKAGES

FORMULA TYPES, SIZES AND MAXIMUM MONTHLY AMOUNTS

All types (including prescription)

A.

TYPE'

SIZE2

MAXIMUM AMOUNTS3

Concentrate

13 ounces

31 cans, 403 ounces concentrate or 806 ounces reconstituted 26.9 ounces per day

Ready-To-Feed

32 ounces

25 cans 800 ounces 26.7 ounces per day

Powdered'

16 ounces (1 pound)

8 cans

14 ounces

9 cans

12 ounces

10 cans

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. 4 Powdered size listed by can weight. Reconstituted amounts vary. Refer to product
label for specific reconstitution instruction.

B. CEREAL AND JUICE MAXIMUM MONTHLY AMOUNTS For Infants 4 Through 12 Months

MAXIMUM AMOUNTS

Infant Cereal

8 ounces

24 ounces

Single Strength Juice

46 fluid ounces OR

92 fluid ounces

Frozen Concentrated Juice reconstituted

12 fluid ounces

96 fluid ounces,

FP - 25

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-2

FOOD PACKAGE NUMBER

. INFANT FOOD PACKAGES
CONTRACT sfBD'i.fIfti FORMULA

I~OUCHER CODE

VOUCHER MESSAGE

112 25 CANS 32 OZ READY TO FEED FE FORTIFIED ENFAMlL OR PROSOBEE

062

FORMULA: : 12-32 OZ CANS READY TO FEED IRON

_____________L: FORTIFIED ENFAMlL OR PROSOBEE _

NO LOW IRON FORMULA ALLOWED

063

FORMULA: : 13-32 OZ CANS READY TO FEED IRON

_____________ L: FORTIF1ED ENFAMlL OR PROSOBEE _

NO LOW IRON FORMULA ALLOWED

113 31 CANS 13 OZ CONCENTRATE FE FORTIF1ED ENFAMlL OR PROSOBEE
STANDARD MANUAL

064

FORMULA: : 15-130ZCANS CONCENTRATED IRON

_____________L: FORTIF1ED ENFAMlL OR PROSOBEE _

NO LOW IRON FORMULA ALLOWED

065

FORMULA: : 16-130ZCANS CONCENTRATED IRON

_____________ 1:.. FORTIFIED ENFAMlL OR PROSOBEE _

NO LOW IRON FORMULA ALLOWED

115 25 CANS 32 OZ READY TO FEED FE FORTIFIED ENFAMlL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL
116 31 CANS 130Z CONCENTRATE FE FORTIFIED ENFAMlL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL

067

FORMULA: : 13-32 OZ CANS READY TO FEED IRON

JUICE

1 ~~~=AN~~~~~~sg:~AN

~_~~~

L~~?_~~?~_~~

~

_

NO LOW IRON FORMULA ALLOWED

071

FORMULA:

!: 12-32 OZ CANS READY TO FEED IRON FORTlFIEDENFAMlLORPROSOBEE

~~~:.

__ L~:~9~_~~_~<:>~<:>~!.~_~~~~

NO LOW IRON FORMULA ALLOWED

068

l~~~=AN~~~~~~sg:~AN FORMULA:
JUICE:

I 16-130ZCANS CONCENTRATED IRON

~_~~

L~~?_~~?~_~~

_

NO LOW IRON FORMULA ALLOWED

072

FORMULA:

!I 15-130ZCANSCONCENTRATED IRON FORTIFIED ENFAMlL OR

I PROSOBEE

I
~~~~ J~=~2_?~_:~_~?~?~_::t~_~~~~__

NO LOW IRON FORMULA ALLOWED

FP - 26

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-2 con't

FOOD PACKAGE NUMBER 117
31 CANS 13 OZ CONCENTRATE IRON FORTIF1ED ENFAMlL OR PROSOBEE 2 CANS JUICE
118 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 16 OZ INFANT CEREAL
123 i!\li@?;~~m:~H#)~ POWDER IRON FORTIF1ED ENFAMIL OR PROSOBEE
126
~~Z;~~~tt.l1m
POWDER FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE
069

VOUCHER MESSAGE

i FORMUlA: i~i~~~C=~:ON

~~~~

_ L!:~_~~_<':~_~~~~~_~~~_~~~_~

NO LOW IRON FORMUlA ALLOWED

072

FORMUlA: : 15-130ZCANSCONCENTRATEDIRON

~~~~ LI~~;r~~~?~:~~~~~FI~ _

NO LOW IRON FORMUlA ALLOWED

072

!i FORMUlA: : 15-13 OZ CANS CONCENTRATED IRON

FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

-----------------------------------------------
NO LOW IRON FORMULA ALLOWED

090

! FORMULA: : 16-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

~_~~ t~~?_~~~~_~_~

_

NO LOW IRON FORMUlA ALLOWED

091 ~~_~:__t!~_~~~~~~}~~:~~ __

NO LOW IRON FORMUlA ALLOWED
__ ~~_~: i~~~~~~~;:~~ __

NO LOW IRON FORMUlA ALLOWED
091 ~~_~:__i!~~~~~j~~~~ __

NO LOW IRON FORMUlA ALLOWED
__ ~:~~l~~~~~~:~~
NO LOW IRON FORMUlA ALLOWED

073

JUICE:

: 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

CEREAL: : UPT0240ZINFANT

FP - 27

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-2 con't

FOOD PACKAGE NUMBER
216 l3CANS l30Z CONCENTRATE IRON FORTIFlED ENFAMlL OR PROSOBEE

VOUCHER

VOUCHER MESSAGE

CODE

092

i FORMUlA:

~~~~~;~~=~

______________L!~<:~<?~~~

_

NO LOW IRON FORMUlA ALLOWED

217 l3CANS l30Z CONCENTRATED FE FORTIFlED ENFAMlL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL
221 2 CANS JUlCE 24 OZ INFANT CEREAL
222 1 CAN 160Z0R 140Z POWDER IRON FORTIFlED ENFAMlL OR PROSOBEE
223
Mlw.1tJ.?lfilmw.1#ii!:$
CANS POWDER IRON FORTIFlED ENFAMlL OR PROSOBEE

____________ _ 092

FORMUlA:

: 13-130ZCANSCONCENTRATED

J;;~~~~~~~:~

NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

2-12 OZ CANS FROZEN (OR) 2-46 OZ CANS UP TO 24 OZ INFANT

073

JUlCE:

CEREAL:

2-12 OZ CANS FROZEN (OR) 2-46 OZ CANS UP TO 24 OZ INFANT

074

FORMULA:

1 CAN (16 OZ OR 14 OZ) POWDER IRON FORTIFlED ENFAMlL OR PROSOBEE

NO LOW IRON FORMULA ALLOWED

_ 075 :~_= J;;f~~~=:!:

NO LOW IRON FORMULA ALLOWED

FP - 28

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-2 con't

FOOD PACKAGE NUMBER
224 I CAN 160Z0R 140Z POWDER FORT1FlED ENFAMlL OR PROSOBEE 2 CANS nnCE 24 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

076

FORMUlA:

I I

I CAN (14 OZ OR 16 OZ) POWDER

I

nnCE:

I IRON FORTJFJED ENFAMlL OR

I

CEREAL:

I PROSOBEE

I

: 2-12 OZ CANS FROZEN OR

: 2-46 OZ CANS

_____________ L~~?_~~?.z_~~~

_

NO LOW IRON FORMUlA ALLOWED

225
!!~~J~i~~~
ENFAMlL OR PROSOBEE
2 CANS nnCE 24 OZ INFANT CEREAL

077

FORMUlA: : 3-160Z0R4-J40ZCANSPOWDER

!~~;~~~D ENFAMlL OR

nnCE: '::!-~~

: 2-12 OZ CANS FROZEN OR 2-46 OZ

: CANS

L~~~?_~~?.z_~.:~~!

_

NO LOW IRON FORMI.nA ALLOVlED

299 BREASTFEEDING
MESSAGE
999 FORMUlA AS ORDERED BY A PHYSICIAN FORMUlA EQUALS 8 LBS OR 403 OZ CONC. OR 800 OZRTF nnCE: 2-46 OZ OR 2-12 OZ FROZEN CANS CEREAL: 24 OZ FORMULA ONLY MAY BE PRESCRlBED

059

NURSE YOUR BABY OFTEN

THE MORE YOU BREASTFEED, THE MORE MJLK YOU

WILL HAVE FOR YOUR BABY

999

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANmy OF SUPPLEMENTAL FOODS FOR THE PARTICIPANTS CATEGORY

FP - 29

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-3

073

JUICE:

C,EREjlip

2-460Z

FP -30

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-3 can't

FP - 31

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-4

It~ N;~Il2,\fi1i!$;~tt:n~im,QJi!
----------- -i-t-W--W-i-i--_-l-P--*--i--'-t-~-------------
mqtmW;m;!:'jJ\n@miWJjl\W!t~~
gQ~ 11_lIIfg'i~mQfl
----------- ---------------------------------
~li~II_~QlE9N
---------------------------------
~i ~ !\@itmWm..fl~~~xm~
wu g~
JRl

FP - 32

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-4 con't

!$.li

l ~1!,
~~

_

fi!Piil@W:)m(Wli@~~

ii~: .,., ,..'.., , ,.,

I

lI
~i

_

i ;mqfQ~

I

___________L

_

F_b_.:RM:t1LA_"'_':'_":'_':'_::::'_':: :,:, __ .________ _

. __'_'ik_':'_<JN_:2'_._

__$tiCE'

_

__

R\*il@Wi{g!f!:PEMti!iM\'i@l'l!!WJtm

~=~ i_~ff1li~~:=:~

_

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_ ~~~J_'I'~~
==_ 11*,-====_ N!il*mW1RID.ffi~~
l[iilmm\Wli.f\\tfl!19~m'4twm1

FP - 33

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-4 con't

_ ~~_J--=:::~~~

~:m,WlAw.mit~~~

~~

~;!

I
~;!I
----------_.!..._----------------------------------

~~~ ! I

p g g j J.m_/:_":FE_;;:"_::":_7

!:

_

_

!l!Q!iQw~PNtQ~!W!i~
_ ==~_Lj~~'_11r~=:~===
li@!Q)itm;:{l)lHt~i~li!~

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NQ;j'i,li!wliRli!~ll~fml\tW!W

~~J~=~ _
lJJi.Wii!tWi~~

FP - 34

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-5

. INFANT FOOD PACKAGES NON-CONTRACT SPECIAL FORMULA
Prescription Required

: ;ii11.W_SiffiWDER
, #m'(hiAP.~liW*~

~

~

m:_@~i

FP - 35

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-5 C9o't

~;.__JI~~~~;.
mw~~~~~
~L__U~~?~l~~g2~1i~;.
===_~Wii~fl:tQ~~~'tg j_"1r~~=~
gPw.:l1RQ*;~:gmB
~===~ LI.llI:=~
l;9W:mQNifQ~~'i'@)P 1!Q~jp;.1

_
__
_

~

~
~~~~__L_ _ifff=:=~=

l;QWJjgQN!i!Q~j!@~Q

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*'tfQi&f@p.*lfm%;~$

_ _ _ _ _ _ _ _ _ _ _ _ _ LI

mWi!R~;~~~
m@1@

_
_

l'$II*Mi'i

FP - 36

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-6

ALTERNATE FOOD PACKAGE FOR INFANTS (0-3 MONTHS)
Maximum Monthly Amounts Contract Standard Formulas

TYPE Ready-To-Feed

SIZE 100-8 fluid oz cans

MAXIMUM AMOUNT 800 fluid ounces

Powder

8-16 oz cans

8 cans

9-14 oz cans

9 cans

12-10 oz cans

10 cans

This food package consist of eight (8) vouchers per month.

FP - 37

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-7

.~~ro
COPE

~*1@~8!~~)NiMtll*@~ ~;@tirRRtJ$\;l~~mflm,9N

___________ .J..

"cc"cc,ccc.,,,.,_c.cc..__ . __ . __ ._~

~1 IIIi"'Bi'.m,9m
----------- --------------------------------j;t:J!J:\l"l'Y"qltP.ktii:~i~;MwfJ!@\m;PWm:l

il'P:~' l~;!Il@'t;!:!~:~M*t;~

f~ ".W'.lltt.m -----------

~mm~J.I$iif~m,9N
---------------------------------

&1l@;\@~:r9~1tt14.llIyID.~

----------- ---------------------------------

&Q1t,{lW~~Wlm

FP - 38

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-8

ALTERNATE FOOD PACKAGE FOR INFANTS (4-12 MONTHS)

Contract Standard Formulas

TYPE Ready-To-Feed Powder
Cereal, Infants Juice

SIZE 100-8 fluid ounces 8-16 oz cans 9-14 oz cans 3-8 boxes, dry 12-6 oz cans

MAXIMUM AMOUNT 800 fluid ounces 8 cans 9 cans 24 ounces 72 ounces

This food package consist of eight (8) vouchers.

FP - 39

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-9

ALTERNATE FOOD PACKAGE FOR INFANTS (4-12 MONTHS)

f~ J;W*W4:~l1s$'M;t~ittfj$\M ----------- -~-A--W--.--t-t--U--~--1-S--~--~--$-$--~--;--~---ii@lkt"i!W;m,~~tlWJ!mi\T4'tJ!ml~
~ Iflll~.illl@l~
----------- --------------------------------Nggmlmf9~mit:@Wl:lP

___________-'-cc._cc,c'"cc'"cccc_. . . .c'"c.ccc

.,

l\~; l~i~;!1lW~~$$Q~ ----------- -~-$--t-;--~-~--j-;-U--~-1--S-I--i-!--R-I--:-m--~---&glk!!l\Wm,m~
~ ".II";ml~
----------- ---------------------------------
Hg,;~W1l!llmif9~t#kt:@Wjm

~__ 11~1f_t===
i'lQgj[lmW9j~'ii.MlM!$1i@_
FP -40

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-IO

WOMEN'S AND CHILDREN'S PACKAGES PRESCRIPTION MAXIMUM AMOUNTS

A.

FORMULA TYPES, SIZES AND ADDITIONAL AMOUNTS

Concentrate

CAN SIZE 13 ounces

MAXIMUM AMOUNTS
31 cans (403 oz concentrate Or 8060z reconstituted)

ADDITIONAL AMOUNTS
4 can (52 oz concentrate or 1040z reconstituted)

Ready-To-Feed

32 ounces

25 cans (800 oz) 3 cans (96 oz)

Powdered oz

16 ounces

8 cans (960 oz reconstituted)

1 can (120 reconstituted)

14 ounces

9 cans (945 oz reconstituted)

1 can (105 oz reconstituted) -

CEREAL AND JUICE MAXIMUM MONTHLY AMOUNTS MAXIMUM AMOUNT

Cereal

9 ounces and above

36 ounces

Single Strength Juice

46 fluid ounces OR

138 fluid ounces

Frozen Concentrate Juice 12 fluid ounces

144 fluid ounces

FP - 41

GA WIC PROCEDURES MANUAL FFY '96

. Attachment FP-ll

WOMEN'S AND CHILDREN'S PACKAGES

Prescription Required

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

312 31 CANS 13 OZ CONCENTRATE FE FORTlFlED ENFAMTI.. OR PROSOBEE
313 25 CANS 130Z CONCENTRATE FE FORTlFlED ENFAMTI.. OR PROSOBEE 2 CANS JUICE 240ZCEREAL
314 25 CANS 32 OZ READY TO FEED FE FORTlFlED ENFAMTI.. OR PROSOBEE 2 CANS JUICE 24 OZ CEREAL

064

NO LOW IRON FORMULA ALLOWED

065

FORMULA: : 16-13 OZ CANS CONCENTRATED

1 IRON FORTlFlED ENFAMTI.. OR

_____________ L~~_<_?~~~~~

_

NO LOW IRON FORMULA ALLOWED

078

FORMULA: : 12-13 OZ CANS CONCENTRATED

I

: IRON FORTlFlED ENFAMTI.. OR

: PROSOBEE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-460ZCAN

____________,;,.IL

_

NO LOW IRON FORMULA ALLOWED

i 079

FORMULA: :;~~~~;=~=~

: PROSOBEE

JUICE: ~~~

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

L.:!.~9_~9~

_

NO LOW IRON FORMULA ALLOWED

If~~~~=:~{~~:~; 080

FORMULA:

JUICE:

____________LI

_

NO LOW IRON FORMULA ALLOWED

081

FORMULA:

!: 13-3202 CANS READY TO FEED IRON FORTIFIED ENFAMTI.. OR PROSOBEE

JUICE:
~_~~~

L::~_~~~~ _ : 1-1202 CAN FROZEN OR 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

FP - 42

GA WIC PROCEDURES MANUAL FFY '96
. VOUCHER CODE

Attachment FP-ll can't
VOUCHER MESSAGE

316 31 CANS 13 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 240ZCEREAL
317 31 CANS 13 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 360ZCEREAL

~ i1mi1$!

@iR~:~

082

FORMULA:

15-13 OZ CANS CONCENTRATED

1 IRON FORTIFIED ENFAMIL OR
,I
[ PROSOBEE

_______________ _ JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ
J_~_~

NO LOW IRON FORMULA ALLOWED

083

FORMULA:

JUlCE:

: 16-13 OZ CANS CONCENTRATED
[
: IRON FORTIFIED ENFAMD_ OR ,
': PROSOBEE 1-12 OZ CAN FROZEN OR 1-460Z

CAN

~_~~~

-, L~!?_:~?~~~~

_

NO LOW IRON FORMULA ALLOWED

082

FORMULA:

! 15-13 OZ CANS CONCENTRATED

!I IRON FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-460Z

_______________JI- CAN

_

NO LOW IRON FORMULA ALLOWED

084

FORMULA:

!:;~~~;~=~~~

JUICE: ~_~~

: PROSOBEE

: 112 OZ CAN FROZEN OR 1-460Z

t CAN
..L~!?_~~?!

_

NO LOW IRON FORMULA ALLOWED

FP -43

GA WIC PROCEDURES MANUAL FFY '96
VOUCHER CODE

Attachment FP-ll con't
VOUCHER MESSAGE

319 35 CANS 13 Ol CONCENTRATE FE FORTIFIED ENFAMlL OR PROSOBEE 2 CANS JUICE 360lCEREAL
322 8-16 Ol CANS OR g-14 Ol POWDER FE FORTIFIED ENFAMIL OR PROSOBEE

pm

i1m~

lliWm:~

084

FORMULA:

: 16-13 CANS CONCENTRATED

~~ 1~;~:;;::::~:

NO LOW IRON FORMULA ALLOWED

086

FORMULA:

j ~O~~gR=~~~~~

: PROSOBEE

________________ _ JUICE:

: 1-12 OZ CAN FROZEN OR 1 -46 OZ 1..9_~

NO LOW IRON FORMULA ALLOWED

091

FORMULA:

!: 4-160ZCANSOR5-140ZCANS POWDER IRON FORTIFIED

_______________l.~~~~~~_<:~?~~~

_

NO LOW IRON FORMULA ALLOWED

FORMULA:

i_~~~!!~

_______________l.~~~~~~~~?~~

_

NO LOW IRON FORMULA ALLOWED

FP-44

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-ll con't

FOOD PACKAGE NUMBER 323
7-16 OZ CANS OR ~-14 OZ POWDER FE FORTIFIED ENFAMlL OR PROSOBEE 3CANsmrCE 240ZCEREAL
326 8-16 OZ CANS OR 9-14 OZ POWDER FE FORTlFIED ENFAMlL OR PROSOBEE 3 CANS mrCE 240ZCEREAL

. VOUCHER CODE

VOUCHER MESSAGE

066

mrCE:

CEREAL:

i: 3-120ZCANSFROZENOR
~~g~;~~CES

075

FORMULA:

: 3-160ZCANS OR4-140Z

______________________1~~~~~~~~

NO LOW IRON FORMULA ALLOWED

FORMULA:

: 4-16 OZ OR 4-14 OZ

i: POWDER IRON
_______________________L!!F-O_cR::T.I<F:I>E~~D~ ENFAMlLOR _

NO LOW IRON FORMULA ALLOWED

066

mrCE:

CEREAL:

i: 3-12 OZCANS FROZEN OR 3-46 OZ CANS : UP TO 24 OUNCES

091

FORMULA:

: 4-160Z0R5-140Z

_______________________lIf~~~~F~~;~_

NO LOW IRON FORMULA ALLOWED

327 8-16 OZ CANS OR ~c14 02 POWDER FE FORTIFIED ENFAMlL OR PROSOBEE
3CANsmrCE
360ZCEREAL

NO LOW IRON FORMULA ALLOWED

070

mrCE:

CEREAL:

: 3-12 OZ CANS FROZEN OR
!t:~~;~~~CES
I I

091

FORMULA:

: 4-160Z0R5-140Z

______________________J: ~PO~WD~E~R I!RO~N F~OR~TI~FIE_D_

NO LOW IRON FORMULA ALLOWED

FORMULA:

: 4-160Z0R4-140ZCANS

---------------------j~~~~~~~

NO LOW IRON FORMULA ALLOWED

FP - 45

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-ll can't

FOOD PACKAGE NUMBER 329
9-16 OZCANS OR 10-14 OZ POWDER FE FORTlFIED ENFAMIT. OR PROSOBEE 3 CANS JUICE 36 OZ CEREAL
332 31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE
333 25 CANS 13 OZ CONCENTRATE FE FORTlFIED LACTOFREE 2 CANS JUICE 24 OZ CEREAL
334 25 CANS 320Z READY-TO-FEED FE FORTIFIED LACTOFREE 2 CANS JUICE 240ZCEREAL
336 31 CANS 130Z CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 240ZCEREAL

VOUCHER CODE 091 093 070 264 265 278
279
280
281
282
283

VOUCHER MESSAGE

__________ _ FORMULA: : 4-160Z0R5-140ZPOWDERIRON J!~_~~_~~_~~.:_~~~~~~

NO LOW IRON FORMULA ALLOWED

___________ _ FORMULA: : 5(140Z 16 OZ)CANS POWDER IRON L!~~~~~_~~_~~.:_~~~~~_E_~

NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

: 3-12 OZ CANS FROZEN OR 3-46 OZ CANS

I I

UP TO 36 OUNCES

I

:~~~:__LI l~~~~~~~~~~_~~~_~~~ __

NO LOW IRON FORMULA ALLOWED

___________ _ FORMULA: : 16-13 OZ CANS CONCENTRATED IRON L!~_~~~~!::~~~~~

NO LOW IRON rORMlJLA ALLOWED

FORMULA: JUICE:

!2-13 OZ CANS CONCENTRATED IRON FORTlFIED LACTOFREE !-12 OZCAN FROZEN OR 1-46 OZ CAN

NO LOW IRON FORMULA ALWWED

FORMULA:
JUICE: CEREAL:

13-13 OZ CANS CONCENTRATED IRON FORTlFIED LACTOFREE 112 OZ CAN FROZEN OR 1-460ZCAN UP TO 24 OZ

NO LOW IRON FORMULA ALWWED

FORMULA: : 12-32 OZ CANS READY TO FEED IRON

JUICE:

1~~~~ANLA~~=R 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

i ~~~:LA~~=R FORMULA: : 13-32 OZ CANS READY-TO-FEED IRON

JUICE:

1-460ZCAN

CEREAL: I UP TO 24 OZ

NO LOW IRON FORMULA ALLOWED

FORMULA: : 15-130ZCANSCONCENTRATEDIRON

JUICE:

!~~~~ANLA~~=R 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

FORMULA:
JUICE: CEREAL:

: 16-13 OZ CANS CONCENTRATED IRON : FORTIFIED LACTOFREE
I
: !-120ZCANFROZENORI-460ZCAN : UPT0240Z

NO LOW IRON FORMULA ALLOWED

FP -46

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-ll con't

FOOD PACKAGE NUMBER 337
31 CANS 130Z CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 36 OZ CEREAL
339 35 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JlTICE 360ZCEREAL
342 9 CANS 140Z POWDERED FE FORTIFIED LACTOFREE
343 8 CANS 140Z POWDERED FE FORTIFIED LACTOFREE 3 CANS JUICE 240ZCEREAL

VOUCHER CODE
282
284
284
286
291 375
066

FORMULA: JUICE:

VOUCHER MESSAGE
15-13 OZ CANS CONCENTRATE IRON FORTIFIED LACTOFREE 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

FORMULA:
JUICE: CEREAL:

I

I 16-13 OZ CANS CONCENTRATED IRON

I

I FORTIFIED LACTOFREE

I

I 1-12 OZ CAN FROZEN OR 1-460ZCAN

I

I I

UP TO 36 OZ

NO LOW IRON FORMULA ALLOWED

FORMULA:
JUICE: CEREAL:

I

I 16-13 OZ CANS CONCENTRATED IRON

I

I FORTIFIED LACTOFREE

I

I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

I

I I

UP TO 36 OZ

NO LOW IRON FORMULA ALLOWED

i FORMULA: : 19-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

JUICE:

: 1-120ZCANFROZENORI-460ZCAN

NO LOW IRON FORMULA ALLOWED

i FORMULA : 5-14 OZ CANS POWDERED IRON FORTIFIED LACTOFREE NO LOW IRON FORMULA ALLOWED
! FORMULA: : 4-14 OZ CANS POWDERED IRON FORTIFIED LACTOFREE NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZCANS UP TO 24 OZ

375

FORMULA: 4-14 OZ CANS POWDERED IRON

FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

375

FORMULA: 4-14 OZ CANS POWDERED IRON

FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

FP - 47

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-ll can't

346
9 CANS 140Z POWDERED FE FORTIFlED LACTOFREE 3 CANS JUICE 240ZCEREAL

066

JUICE:

CEREAL:

291

FORMULA:

NO LOW IRON FORMULA ALLOWED 375

347
9 CANS 140Z POWDERED FE FORTIFIED LACTOFREE 3 CANS JUICE 36 OZ CEREAL

NO LOW IRON FORMULA ALLOWED

070

JUICE:

iti,2T~~~';;2 FROZEN OR 3-46 OZ CANS

CEREAL:

291

! FORMULA: : 5-14 OZ CANS POWDERED IRON FORTIFlED LACTOFREE

NO LOW IRON FORMULA ALLOWED

375

i FORMULA: : 4-14 OZ CANS POWDERED IRON FORTlFlED LACTOFREE

NO LOW IRON FORMULA ALLOWED

fQ~ ! I

FP -48

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-ll cQn't

999 FORMULA IS ORDERED BY A PHYSICIAN FORMULA EQUALS 8-9 LBS POWDER OR 9-10,14 OZ POWDER 403-455 OZ CONC. 800-910 OZ RTF; 3-12 OZ FROZEN CANS 36 OZ CEREAL
FORMULA ONLY MAY BE PRESCRIBED

999

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANTS CATEGORY

FP - 49

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-12

ALTERNATE FOOD PACKAGES FOR CHILDRENIWOMEN WITH SPECIAL DIETARY NEEDS
Maximum Monthly Amounts

FOOD
Ready-T o-Feed Formula

SIZE

MAXIMUM MONTHLY AMOUNTS

ADDITIONAL AMOUNTS

100-8 oz cans

8000Wlces

12-8 oz cans (96oWlceS)

Cereal

4-9 oz bo~cs

36 ounces

Juice

23-6 oz cans

1380Wlces

This food package consists ofeight (8) vouchers

FP - 50

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-13

ALTERNATE FOOD PACKAGES FOR WOMEN AND CHILDREN WITH SPECIAL DIETARY NEEDS

FP - 51

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-14

CHll..DREN'S FOOD PACKAGES AUTHORIZED MAXIMUM OUANTITY OF SUPPLEMENTAL FOODS

FOOD Milk'

MAXIMUM AMOUNT PER MONTH 24 quart equivalentsl

Cheese

4 pounds2

Eggs

2 dozen

Juice

6-46 oz cans or 6-12 oz frozen

Cereal

36 ounces

Dried Beans/Peas or Peanut Butter

I pound bags or 18 ounce jar

'Substitution amounts for fluid milk include:

FLUID MILK EOUIVALENTS

Cheese, 1 pound

3 quarts

Evaporated milk, whole or skim (13 oz) 1 quart

Dry whole milk, 1 pound

3 quarts

Nonfat or lowfat dry milk, 1 pound

5 quarts

2 Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance.
3 Substitute up to 24 quarts ofLactose reduced milk to replace up to 6 gallons of milk.

FP - 52

GA WIC PROCEDURES MANUAL FFY '96 CHILDREN'S FOOD PACKAGES

Attachment FP-15

FOOD PACKAGE NUMBER
MINIMUM 600
2GALSMlLK 1 LBCHEESE 1 DOZEGGS 180ZCEREAL 4 CANS JUICE
MINIMUM 601
4 GALS MILK lDOZEGGS 4 CANS JUICE 240ZCEREAL I LB BEANSII'EAS OR 180Z PEANUT BUTTER

VOUCHER CODE 042
040

CHEESE: JUICE: MILK:
JUICE

VOUCHER MESSAGE
, UP TO I LB
,i 1-12 OZ CAN FROZEN OR 1-46 OZCAN
,, 1 GALOR4-120ZCNSEVAP
i ~~21~Z~~O~OZENOR 1-460ZCAN

039

MILK:

: 1 GAL OR 4-12 OZCNSEVAP

EGGS: JUICE:

!~~~iE~T BOX
,, 1-12 OZ CAN FROZEN OR 1-46 OZCAN

049

JUJCE: CEREAL:

,,, 1-12 OZ CAN FROZEN OR 1-460ZCAN ,, UP TO 1ROUNCES

040

MILK: JUICE:

i: 1 GALOR4-120ZCNSEVAP
~~21~Z~~O~OZENOR 1-460ZCAN

039

MILK:

EGGS:

: 1 GALOR4-120ZCNSEVAP
j ~~iciTBOX

JUICE:

: 1-12 OZ CAN FROZEN OR 1-460ZCAN

040

MILK:

,, I GAL OR 4-12 OZ CANS EVAP

JUICE:

j ~~21~Z~~O~OZEN OR 1-46 OZ CAN

037

MILK:

,, I GAL OR 4-12 OZ CANS EVAP

JUICE:

!~~21~Z~~0~OZENOR 1-460ZCAN

CEREAL:

: UP TO 24 OUNCES

BEANSII'EASI : I LB DRIED BEANSII'EAS OR

,, PEANUT

,, BUTTER:

18 OZ PEANUT BUTTER

FP - 53

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-lS con't

FOOD PACKAGE NUMBER 602
LIMITED MJLK LACTOSE INTOLERANT
2GALSMJLK 2LBSCHEESE 2DOZEGGS 4 CANS JUICE 240ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUT BUTTER
MODERATE 603' 4 GALS MJLK lLBCHEESE 2 DOZEN EGGS 4 CANS JUICE 240ZCEREAL 1 LB BEANSIPEAS
, STANDARD MANUAL

VOUCHER CODE

VOUCHER MESSAGE

<l42

CHEESE:

UP TO 1 LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

<l43

CHEESE:

I
I UP TO 1 LB

I

JUICE:

I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

I

BEANSIPEAS! : 1 LB DRIED BEANSIPEAS OR

PEANUT BUTTER:

I
:I 18 OZ PEANUT BUTTER

048

MJLK:

I GAL OR4-12 OZ CANS EVAP

EGGS: JUICE:

OR 1-5 QT BOX I DOZEN 1-120ZCANFROZENOR 1-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

039

MILK:

EGGS: JUICE:

,I

I,

I GALOR4-120ZCANSEVAP OR 1-5 QT BOX

I

I I DOZEN

I

I I

1-12 OZ CAN FROZEN OR 1-460ZCAN

<l47

MJLK:

:I
I

I GAL OR 4-12 OZ CANSEVAP

OR 1-5QTBOX

I

JUICE:

I 1-12 OZ CAN FROZEN OR 1-460ZCAN

I

CEREAL:

1 UP TO 24 OUNCES

039

MJLK:

!~~~~~~~xOZCANSEVAP

EGGS: JUICE:

: lDOZEN : 1-12 OZ CAN FROZEN OR 1-460ZCAN

025

MJLK:

!: 1 GALOR4-12 OZCANS EVAP OR 1-5QTBOX

CHEESE:

: UPTOILB

JUICE:

: 1-120ZCANFROZENORI-460ZCAN

BEANSIPEASJ :

PEANUT BUTTER:

I

I

I I

1 LB DRIED BEANSIPEAS

039

MJLK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP ORI-5QTBOX I DOZEN .1-12 OZ CAN FROZEN OR 1-46 OZ CAN

FP-54

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-15 con't

FOOD PACKAGE NUMBER 604
4 GALS MILK 2LBSCHEESE 2 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL I LB DRIED BEANSIPEAS OR 18 OZ PEANUT BUTTER
605 LACTOSE REDUCED MILK LACTOSE INTOLERANT 16 QTS LACTOSE REDUCED MILK 2 LBS CHEESE 2DOZEGGS 6 CANS JUICE 240ZCEREAL I LB BEANSIPEAS OR 18 OZ JAR PEANUT BUTTER

VOUCHER CODE

031

MILK:

CHEESE: JUICE:

VOUCHER MESSAGE

I I

1 GAL OR 4-12 OZ CANS EVAP

I

I OR 1-5QTBOX

I

I UP TO I LB

:I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

037

MILK:

I GALOR4-120ZCANSEVAP

OR 1-5QTBOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

BEANSIPEASI

I LB DRIED BEANSIPEAS OR

PEANUT

BUTTER:

18 OZ PEANUT BUTTER

039

MILK:

EGGS: JlJlCE

I I GAL OR 4-12 OZ CANS EVAP

! OR 1-5QTBOX

I

,,,,

I DOZEN 1-12 OZCAN FROZEN OR

1-46 OZCAN

055

MILK:

CHEESE: EGGS: JUICE:

I GALOR4-12 OZ CANS EVAP OR 1-5QTBOX UPTOILB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

044

MILK:

CHEESE: JUICE: CEREAL:

4 QTS OR 2-1/2 GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE UP TO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 24 OUNCES

034

MILK:

EGGS: JUICE:

!I
I

4 QTS OR 2-1/2 GAL ACIDOPHILUS

ENJOY, LACTAID, LACTAID 100,

: NUTRISH,DAIRYEASE

iI I DOZEN 2-120ZCANFROZENOR2-460ZCAN

! 045

MILK:

=~if:tis~~~~S

CHEESE: JUICE: BEANSIPEAS/ PEANUT BUTTER:

: UP TO ILB
: 1-120ZCANFROZENORI-460ZCAN
: I LB DRIED BEANSIPEAS OR
I
! 18 OZ PEANUT BUTTER

034

MILK:

EGGS: JUICE:

,I
I 4 QTS OR 2-1/2 GAL ACIDOPHILUS

I ENJOY, LACTAID,LACTAID 100,
I
!, NUTRJSH, DAIRY EASE I DOZEN

I I

2-12 OZ CAN FROZEN OR 2-46 OZ CAN

FP-55

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP - 15 con't

FOOD PACKAGE NUMBER
606
4 GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 360ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUr B\JlTER

VOUCHER CODE

028

MILK:

EGGS: JUlCE:

031

MILK:

CHEESE: JUICE:

054

MILK:

CHEESE: EGGS: JUICE:

VOUCHER MESSAGE
I GAL OR 4-12 OZ CANS EVAPOR 1-5 QT BOX I DOZEN 1-12 OZ CANS FROZEN OR 1-46 OZ CANS
I GALOR4-12 OZ CANS EVAPOR 1-5QTBOX UP TO 1 LB 1-12 OZ CANS FROZEN OR 1-46 OZ CAN
1 GAL OR 4-12 OZCANS EVAPOR 1-5QTBOX UP TO I LB I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

056

MILK:

I GAL OR 4-12 OZ CANS EVAI' OR

1-5 QTBOX

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CAN

CEREAL:

UP TO 36 OUNCES

BEANS/PEAS/

I LB DRIED BEANSIPEAS OR

["NUT BUTTER: 18 OZ PEANUr B\JlTER

MAXIMUM 607

6 GALS MILK 2 DOZEN EGGS 6 CANS JUICE 360ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUr B\JlTER

028

MILK:

EGGS: JUICE:

I GAL OR4-12 OZ CANS EVAPOR 1-5 QT BOX 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

032

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3QTBOXES I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

046

MILK:

JUICE:

I GAL OR 4-12 OZ CANS EVAPOR 1-5QTBOX 1-12 OZ CANS FROZEN OR 1-46 OZ CANS

999*

999

AS PRESCRlBED

6 GALS OR 24 QTS MILK

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH

4 LBSCHEESE

MUST NOT EXCEED THE MAXIMUM QUANTITY OF

2 DOZEN EGGS

SUPPLEMENTAL FOODS FOR THE PARTICIPANTS

6 CANS JUICE

CATEGORY.

360ZCEREAL

1 LB BEANSIPEAS OR

18 OZ PEANUr B\JlTER

* A maximum of 2 pounds of cheese per month is recommended except for those with laclose intolerance

FP-56

GA WI PROCEDURES MANUAL FFY '96

Attachment FP-16

ALTERNATE FOOD PACKAGES FOR CHILDREN 1-5 YEARS

Maximum Monthly Amounts

FOOD UHf Milk
Lactose Reduced Milk

SIZE

MAXIMUM AMOUNTS

96-8 oz boxes

768 ounces

OR

22 quarts or I 1 - Y:i gallons 704 ounces

Cereal Juice Peanut Butter

4-9 oz boxes 42-6 oz cans 2-18ozjars

36 ounces 252 ounces 36 ounces

This food package consist of eight (8) vouchers.

FP-57

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-17

ALTERNATE FOOD PACKAGES FOR CHILDREN 1-5 YEARS

MItK:
liJlCE:

~i
i~ mwff

!!~4

MWKi

@Jl~ ~j;;

FP-58

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-18

WOMEN'S FOOD PACKAGES AUTHORIZED MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS

FOOD
Milk Cheese Eggs Juice
Cereal Dried BeansfPeas or Peanut Butter

PREGNANT, BREASTFEEDING AND NON-BREASTFEEDING

EXCLUSIVELY BREASTFEEDING S

28 quart equivalents 2,3

28 quart equivalents

4 pounds 4

1 pound

2 dozen

2 dozen

6-46 oz cans or 6-12 oz cans frozen

7-46 oz cans or 7-12 oz cans frozen

36 ounces

36 ounces

I pound bag or 1-18ozjar

Carrots 5
Tuna 5 1 Substitution amounts for fluids milk include:

2 pounds, fresh, whoJe
4-{1 oz cans

ITEM
Cheese, 1 pound
Evaporated milk whole or skim (13 oz)
Dry whole milk 1 pound
Nonfat or lowfat dry milk, 1 pound

FLUID MILK EQUIVALENTS
3 quarts 1 quart
3 quarts
5 quarts

2 Subtract from montbly milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance.
,. Substitute up to 28 quarts of reduced milk for up to 7 gallons of mail . Substitute up to 4 lbs cheese for up to 7 gallons of milk. s. Additional items authorized for exclusively breastfeeding women only.

FP-59

GA PROCEDURES MANUAL FFY '96

Attachment FP- 19

PREGNANT AND BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM401
4 GALS MILK l00ZEGGS 4 CANS nJICE 24 OZ CEREAL 1 LB BEANSIPEAS OR 18 OZ PEANUT BUTTER
402 LIMITED MILK LACTOSE INTOLERANT 2 GALS MILK 2 LBS CHEESE 200ZEGGS 6 CANS nJICE 360ZCEREAL 1 LB BEANSIPEAS OR 180ZPEANUTBUTTER

VOUCHER CODE

040

MILK:

nJICE:

039

MILK:

EGGS: nJICE:

VOUCHER MESSAGE
: 1 GAL OR 4-12 OZCANS EVAP OR
i 1-5QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
,,, 1 GAL OR 4-12 OZ CANS EVAP OR ,I 1-5QTBOX ,,,I l00ZEN
1-12 OZ CAN FROZEN OR 1-46 OZ CAN

037

MILK:

1 GAL OR4-12 OZCANS EVAP OR

1-5 QT BOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

BEANSIPEAS/

1 LB DRJED BEANS/PEAS OR

P'NUT BUTfER: 18 OZ PEANUT BUTTER

040

MILK:

nJICE:

,,, 1 GAL OR4-12 OZ CANS EVAP OR
: 1-5 QT BOX
I l-120ZCAN FROZEN OR 1-4GOZCAN
I

041

MILK:

EGGS:

: 1 GALOR4-12 OZ CANS EVAP OR

I I

1-5QTBOX

I

: lOOZEN

CEREAL:

: 2-12 OZ CANS FROZEN OR 2-46 OZ

nJICE:

: CANS UP TO 36 OUNCES

042

CHEESE:

nJICE:

028

MILK:

EGGS: nJICE:

:, UP TO I LB ,,, 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I I
,I 1 GAL OR 6-12 OZCANS EVAPOR
I
, 1-5QTBOX
I
: lOOZEN
: 2-12 OZ CAN FROZEN 01.<. 2-46 OZ CANS

043

CHEESE:

UP TO 1 LB

nJICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

BEANSIPEASI

1 LB DRJED BEANSIPEAS OR

P'NUT BUTTER: 180ZPEANUTBUTTER

FP-60

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-19 con't

FOOD PACKAGE NUMBER
MODERATE 403 4 GALS MILK 1 LBCHEESE I DOZEGGS 4 CANS ruICE 240ZCEREAL 1 LB BEANSiPEAS OR 18 OZ PEANUT BUTTER
404* 4 GALS MILK 2 LBS CHEESE 2DOZEGGS 6 CANS ruICE 240ZCEREAL 1 LB BEANSiPEAS OR 18 OZ PEANUT BUTTER
*STANDARD MANUAL

VOUCHER CODE
037

VOUCHER MESSAGE

MILK:

i IGALOR4-120ZCANSEVAPOR

ruICE:

!, 1-5QTBOX l-120ZCANFROZENOR 1-460ZCAN

,, CEREAL:

: UP TO 24 OUNCES

BEANSiPEASI

I LB DRlED BEANSiPEAS OR 18 OZ

P'NUT BUTTER: : PEANUT BUTTER

039

MILK:

EGGS: ruICE

031

MILK:

CHEESE: JUICE:

040

MILK

JUICE-

!I 1 GAL OR4-12 OZ CANS EVAP OR 1-5 QT BOX

i I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZCAN

,,, 1 GAL OR 4-12 OZCANS EVAPOR

,,,,

1-5 UP

QT TO

BOX 1 LB

,, 1-12 OZ CAN FROZEN OR 1-46 OZCAN

,,,,,

1 GAL OR 4-12 OZCANS 1-5 QT BOX

EVAP OR

,I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

028

MILK:

EGGS: ruICE:

031

MILK:

l,, I GAL OR 6-12 OZ CANS EVAP OR 1-5 QT BOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ
!: CANS
,,, 1 GAL OR 4-12 OZ CANS EVAPOR

CHEESE: JUICE:

,,,,I 1-5QTBOX
I
UP TO I LB 1-12 OZCANFROZENOR 1-460ZCAN

037

MILK:

,,, I GAL OR 4-12 OZCANS EVAP OR

ruICE:

,,I 1-5QTBOX 1-120ZCANFROZENOR 1-46 OZ CAN

CEREAL:

,i UP TO 24 OUNCES

:, BEANSiPEASI

I LB DRlED BEANSiPEAS OR

P'N\.IT BUTTER: 18 OZ PEANUT BUTTER

054

MILK:

CHEESE:

,, I GAL OR 4-12 OZCANS EVAPOR ,,, 1-5QTBOX ,, UP TO I LB

EGGS:

: lDOZEN

JUICE:

: 2-12 OZ CAN FROZEN OR 2-46 OZ CAN

FP-6!

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-19 can't

FOOD PACKAGE NUMBER
405
LACTOSE REDUCED MILK
LACTOSE INTOLERANT
12 QTS LACTOSE REDUCED MILK 3 LBS CHEESE 2DOZEGGS 6 CANS JUICE 360ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUT BUTTER

I I VOUCHER CODE

033

MILK:

CHEESE: JUICE: CEREAL:
MILK: 034

VOUCHER MESSAGE
I~~y~~~~~~~~~S
: NUTRISH.DAIRYEASE : UPTOILB : 1-12 OZ CAN FROZEN OR 1-460ZCAN : UP TO 36 OUNCES
:~~~i~1:s~~~~S

EGGS: JUICE:

: I DOZEN : 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

035

MILK:

2 QTS OR Y, GAL ACIDOPHILUS ENJOY,

LACTAID, LACTAID 100, NUTRJSH,

DAIRY EASE

CHEESE:

UP TO I LB

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS

BEANSfPEAS/

I LB DRIED BEANSIPEAS OR

p'Nur I3lmTR: 18 OZ PEANUT BUTTER

036

MILK:

CHEESE: EGGS: JUICE:

!: 2 QTS OR 'I, GAL ACIDOPHILUS, ENJOY, LADTAID, LACTAID 100, NlITRJSH, : DAIRYEASE : UP TO 1 LB : 1 DOZEN
,: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I

FP-62

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-19 con't

FOOD PACKAGE NUMBER 406
5 GALS MILK 2LBSCHEESE 2 DOZEN EGGS 6 CANS JUICE 360ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUT BUTTER
MAXIMUM 407 7 GALS MILK 2 DOZEN EGGS 6 CANSJUlCE 360ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE

VOUCHER MESSAGE

027

MILK:

!: 2GALOR8--120ZCANSEVAPOR i&~WitMi,f:&

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 36 OUNCES

BEANSIPEASf

I LB DRJED BEANSIPEAS OR

P'NUT BUTTER: 18 OZ PEANUT BUTTER

028

MILK:

EGGS: JUICE

I GAL OR 6-12 OZCANS EVAPOR 1-5 QT BOX I DOZEN 1-12 OZ CANS FROZEN OR 2-46 OZ CANS

031

MILK:

CHEESE: JUlCE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5QTBOX
! UP TO 1 LB
:, ]-12 OZ CAN FROZEN OR 1-460ZCAN

054

MlJ.K:

CHEESE: EGGS: JUlCE:

1GALOR4-12 OZCANS EVAPOR 1-5 QT BOX UPTOILB 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CAN

027

MILK:

: 2GALOR8-120ZCANSEVAPOR

JUICE:

!: 2-3QTBOX 1-12 OZCANFROZEN OR 1-460ZCAN

,,,, CEREAL:

: UP TO 36 OUNCES

BEANSIPEASf

1 LB DRJED BEANSIPEAS OR

P'NUT BUTTER: 18 OZ PEANUT BUTTER

028

MILK:

,, I GAL OR 6-12 OZCANS EVAPOR ,, 1-5QTBOX

EGGS:

I DOZEN

JUlCE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS

029

MILK:

JUICE:

2 GAL OR 8--12 OZ CANS EVAP OR 2-5QTBOXES 1-12 OZ CAN FROZEN OR 1-460ZCAN

030

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5QTBOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

FP-63

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP- 19 can't

FOOD PACKAGE NUMBER
408' EXCLUSIVELY BREASTFEEDING
7 GALS MILK I LBCHEESE 2 DOZEN EGGS 7 CANS JUICE 360ZCEREAL
2LBS CARROTS
4 CANS TUNA

VOUCHER
CODE

VOUCHER MESSAGE

001

CHEESE:

JUICE:

CARROTS:

TUNA:

BEANSIPEAS:

027

MILK:

i: 2GALOR8-120ZCANSEVAPOR ~\\t:ltt\!'ilQK

JUICE:

: 1-120ZCANFROZENORI-460ZCAN

CEREAL:

: UP TO 36 OUNCES

BEANSIPEAS/ : I LB DRIED BEANSIPEAS OR

P'NUT BUTTER: : 18 OZ PEANUT BUTTER

028

MILK:

EGGS: nnCE:

1 GAL OR 6-120ZCANS EVAPOR 1-5 QTBOX J DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

029

MILK:

JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR
!.i;$ifttj'@jxg$
1-12 OZ CAN FROZEN OR 1-46 OZCAN

999
7 GALS OR 28 QTS MILK 4 LBS CHEESE 2 DOZ EGGS 7 CANS JUICE 360ZCEREAL I LB BEANSIPEAS OR 18 OZ PEANUT BUTIER

030

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR ~k'$JQ$$9~ I DOZEN
2-120Z CANS FROZEN OR 2-46 OZ
CANS

999

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANTS
CATEGORY

'a. Food package 408 can be issued to the mother immediately after delivery, Food package 999, voucher code 99. may be tailored for exclusively breastfeeding women not to exceed Jhe maximum amounts listed in package 408.
b. Substitution for food package 408 only: 1. 5 gallons of milk and 2 100. cheese to replace 7 gallons of milk 2. 4 100 cheese to replace 7 gallons of milk
**c. A maximum of2 pounds of cheese per month is recommended except for those with lactose intolerance.

FP-64

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP - 20

ALTERNATE FOOD PACKAGES FOR PREGNANT AND BREASTFEEDING WOMEN
Maximum Monthly Amounts

FOOD UHTMilk

PREGNANT,AND BREASTFEEDING
[[2-8oz boxes

EXCLUSIVELY BREASTFEEDING
[52 - 8 oz boxes

Lactose Reduced Milk

OR [6 quarts or 8 - 'I, gallons

3 [ quarts or [5 - Vi gallons

Cereal

4-9 oz boxes

4-9 oz boxes

Juice

45 - 6 oz cans

56-6 oz cans

Peanut Butter

2-18ozjars

Beans/Peas

Tuna

Carrots

TIlls food package consists of 8-9 vouchers

3-[8ozjars 4-15 oz cans 6-6ozcans 2-150z cans

FP-65

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-21

~)

~;

;1P1pg,

611

MlPK;

tQli:;;

~

M!!'1

fIlM

@

~

EfM

~.

~

~;

FP-66

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-21 con't

FP-67

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-22

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES AUTHORIZED MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS

FOOD

MAXIMUM AMOUNT PER MONTH

Milk'

24 quart equivalents'

Cheese

4 pounds2

Eggs

2 dozen

Juice

4-46 oz cans or 4-12 oz frozen

Cereal

36 ounces

, Substitution amounts for fluid milk include:

ITEM

FLUID MILK EQUIVALENTS

Cheese, 1 pound

3 quarts

Evaporated milk, whole or skim (13 oz) 1 quarL

Dry whole milk, 1 pound

3 quarts

Nonfat or lowfat dry milk, 1 pound

5 quarts

2 Subtract from montWy milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance.

3 Substitute up to 24 quarts oflactose reduced milk to replace up to 6 gallons of milk.

FP-68

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-23

POSTPARTUM, NON~BREASTFEEDINGWOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM 501 3 GALS MILK 1 DOZEN EGGS 3 CANS JUICE 180ZCEREAL
502 '" 3 GALS MILK 2 LBS CHEESE lDOZEGGS 4 CANS JUICE 240ZCEREAL
'STANDARD MANUAL

VOUCHER CODE
040

MILK:

JUJCE

040

MILK:

JUICE:

053

MILK:

CEREAL:

052

JUICE:

EGGS:

040

MILK:

JUJCE:

042

CHEESE:

JUICE

047

MILK:

JUICE: CEREAL:

055

MILK:

CHEESE:

EGGS:

JUICE:

VOUCHER MESSAGE
,,I 1 GAL OR4-12 OZCANS EVAP OR , 1-5QTBOX
I
I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I

I I

1 GAL OR 4-12 OZCANS EVAPOR

I

I 1-5QTBOX

I

I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

I

I I

1 GAL OR 4-12 OZ CANS EVAP OR

,I
I 1-5QTBOX

I UP TO 18 OUNCES
,,,I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
: 1 DOZEN

:I 1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX
! 1-120ZCAN FROZEN OR 1-460ZCAN

I I

UP TO 1 LB

I

I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

I

,I 1GALOR4-12 OZCANS EVAPOR

I I

1-5QTBOX

I
1-12 OZ CAN FROZEN OR 1-46 OZ CAN
:,I UP TO 24 OUNCES

1 GAL OR 4-12 OZ CANS EVAP OR 1-5QTBOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-460ZCAN

FP-69

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-23 con't

FOOD PACKAGE NUMBER
MAXIMUM 503
6 GALS MILK 2 DOZEN EGGS 4 CANS JUICE 360ZCEREAL

VOUCHER CODE

050

MILK:

EGGS: JUICE: CEREAL:

051

MILK:

JUICE:

039

MILK:

EGGS: JUICE:

051

MILK:

JUICE:

Sal

MILK:

VOUCHER MESSAGE
I GAL OR 4-12 OZ CANS EVAP OR 1-5QTBOX I DOZEN 1-120Z CAN FROZEN OR 1-46 OZ CAN UP TO 36 OUNCES
2 GALS OR 8-12 OZ CANS EVAP OR
~~Qml~*
1-120Z CAN FROZEN OR 1-46 OZ CAN
I GAL OR 4-12 OZ CANS EVAPOR 1-5QTBOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
2 GALS OR 8-12 OZCANS EVAP OR 2-5 QT BOX 1-12 OZCANFROZENOR 1-460ZCAN

999*

999

AS PRESCRIBED

6 GALS OR 24 QTS MILK SUBSTITUTE I LB CHEESE FOR 3 QTS MILK 2 DOZEN EGGS 4 CANS JUICE 360ZCEREAL

A TAILORED PACKAGE DESIGNED BY THE CPA
MUST NOT EXCEED THE MAxiMuM QUANTITY OF
SUPPLEMENTAL FOODS FOR THE PARTICIPANTS CATEGORY

A maximum of2 pounds ofcheese per month is recommended except for those with lactose intolerance

FP-70

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-24

ALTERNATE FOOD PACKAGE FOR POSTPARTUM, NON-BREASTFEEDING WOMEN

Maximum Monthly Amounts

FOOD

SIZE

UHTMilk

72-8 oz boxes

OR

Lactose Reduced Milk

18 quarts or 9-112 gallons

Cereal

4-9 oz boxes

Juice

30-6 oz cans

Peanut Butter

1-18ozjar

This food package consists of eight (8) vouchers.

MAXIMUM AMOUNT 576 ounces
36 ounces 184 ounces 18 ounces

FP-71

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-25

ALTERNATE FOOD PACKAGES FOR POSTPARTUM, NON-BREASTFEEDING WOMEN

~

~

lIP

FP-72

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-26

GEORGIA WIC FORMULA REFERRAL FORM" (To Be Completed By Referral Agency)

DATE: TO: FROM:
PHONE#:

WICPROGRAM SignaturerritJe (physician) Health Facility - Location

I. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ is a resident 01"

_

He/She receives tr1.':31111e111 for

_ His:/l-J'er local physician is

_

Please provide this fonnula for

OW1CCS of montn.<\.

fannula monthly. I estimate he/she will need

2. Check the correct statement:
o This client has been assessed for the WIC Program. A WIC Program Assessment/Certification is attached.
o Please assess this client for the WIC Program. The following information was collected on

LengthlHeight*

_

Weight*

_

HematocritfHemoglobin**

_

3. Diet Order: Please list other WIC approved foods allowed and any follow-up diet instructions. The WIC Program authorizes the following distribution to infants and children: lnfants- 4 months old up to 92 ounces offiuit juice and 24 ounces ofinfant cereaL Children - up to 4 quarts offiuit juice and 36 ounces o f cereaL

* Sample Form. May be adapted for local agency use. ** Please include this information, if available.
FP-73

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-27

GEORGIA WIC APPROVED FOOD liST CRITERIA TO EVALUATE AN ELIGffiLE FOOD ITEM

I. Administrative Adjustments

A A food company interested in participating in U,e Georgia WlC Program should submit distribution, cost, and nutrient infonnation on a food item(s) to the Office of Nutrition* by October 1st ofeach year.

B. A review of potentially new food items shall be conducted biennially. ** Consequently, the WlC Approved Food List shall be printed biennially only.

C. A product must be conunercially available as a brand name, or a store brand for a rninimwn of twelve (I 2) consecutive months prior to October I st of each year.

D. The food item cost CalUlot exceed 10 percent (l 0%) of the State average cost per ounce for that food group. Food groups include:

I. Milk 2. Eggs 3. Cereal 4. huant Cereal 5. Tuna

6. Chee::-e 7 Juice 8. Dried BeanslPeas and Peanut Butter 9. Carrots

E. Food item must be acceptable to participants.

II. Nutrition Ouality

A. Cereal - Adult

I. Contains a minimum of 28 mg. of iron per 100 gm. ofdry cereal. 2. Contains not more than 14.1 gm. of sucrose and other sugars per 100 gm. of dry cereal (less
than 4 gm. per ounce). 3. Contains not more than 500 mg. of sodium per I ounce ofdry cereal. 4. Contains no artificial or non-nutritive sweeteners.

B. Cereal - Infant I. Contains a minimum of45 mg. ofiron per 100 gm. ofdry cereal. 2. Contains no added sugar. 3. Contains no added fiuit. 4. Contains no added fonnula

C. Milk I. 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 Buttemtilk or Goat's milk.

D. Cheese I. Domestic Cheese (pasteurized, processed American, Monterey Jack, Colby, Natural Cheddar, Mozzarella).

FP-74

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-27 con't

E. Peanut Butter and ~jDried Beans and Peas 1. Including, but not limited to: black, nary, kidney, garbanzo, soy, pinto and mung beans; crowder, cow, split and blackeyed peas; lentils. 2. No flavored beanslpeas allowed. 3. No peanut butter and jelly or honey combinations.

F. Juice I. Single strength or frozen concentrate 100% fruit juice. 2. 30 mg. vitamin C per 100 mL of reconstituted juice, minimum. 3. Contains no added sugar 4. Contains no added calcium 5. No infant juices allowed

G. Eggs I. Whole, large, grade A

H. Carrots I. Mature, raw or Calmed, packaged in ,,,,rater only.

Tuna 1. 100% tuna, wala po.cked only.

A Food must be prepackaged, no bins.
B. Cereal (adult and infant) I. No single serving containers. 2. Adult cereal weight must be in whole numbers, minimum of9 ounces, not to exceed 36
OWlceS.
3. Infant cereal only in eight (8) ounce packages.
C. Cheese I. 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. A minimum of 9 ounces, not to exceed 16 ounces.
D. Juice I. No aingle serving containers. 2. No fresh squeezed. 3. Containers must be easily and clearly identified as fortified with 30 mg. ofvitarnin C per 100 mi. ofjuice, except orange juice and grapefruit juice. 4. Forty-six (46) ounce cans 12 ounce frozen cans @f'~;lii:9.q1.
E. Eggs I. One dozen size carton ouly.
F. Milk I. One gallon size only tor Whole, Skim, 99% Fat Free (1%), Fat Free (\6%) Lawfat (2%) milk. 2. One-half gallon or quart size containers only for Lactose Reduced milk. 3. Twelve ounce cans only for Evaporated milk 4. Three or 5 quart boxes for Powdered milk.
FP-75

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-27 con't

G. Carrots I . One pound plastic bag, pre-packaged with wire or adhesive tape@ffiW.$il!m~l!ljili
H. Tuna I. 6 ounce can only.
l. Peanut Butter I. 18 ounce jar only.
1. Dried BeanslPeas I. I pound bag 9\l1~i?Wi!*@(Ri1l.ii!
IV. Formula
A. Complete FOITI1ula I. Iron fortified. infant fonnula v,,.hieh contains at least I0 mg. iron per liter oftoffi1Ula at standard dilution 2. 67 keal. per milliliter (approximately 20 keal. per fluid ounce at standard dilution).
B. Fonnula Not Meeting the Requirements for a Complete Formula 1. Fonnula intended for use as an oral feeding and prescribed by a physician when the participant has a medical condition which precludes the use ofconventional fonnula or food. 2. Allow supplements to be used in conjunction with an appropriate prorated food package. Substitute a specified amount ofsupplement per quart or can ofmilk or formula.

Address: Georgia Division of Public Health, Office of Nutrition, 2 Peachtree Street, NW. Suite 84:13. Atlanta. Georgia 30303
Biennial review ofthe WIC Food List does not necessarily constitute a change in the food list. Changes to the WIC Approved Food Ust shall occur mOTe frequently only to acconunodate Federal mandates.07194

FP-76

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-28

FOODlTEM MILK (pasteurized)
CEREAL
CHEESE
JUICE (lOOV. USRDA Vitamin C Fortified)

Georgia WTC Program WTC APPROVED FOOD LIST

~'.tbefoDowinl1:listorfoocismavbc:DUJthasedusin2wtCYOUebers:

BRAND ORTYPE

CONTAINERIPACKAGESIZE

Whole, Skim. 99"'/0 Fat Free. Of Low Fat (2".4) (Least Expensive Brand ONLY)
Acidophilus., Enjoy, LACTAID. Lactaid 100. or Daily Ease
(Evapor31Cd or Powder)

Onc(l) Gallon Size ONLY (Exception: 'is Gallons or Quarts of Enjoy. Lsctaid. Lactaid 100. Dairy Ease. and/or Acidophilus., l2-Ouno::: Cans Evaporated. 3-5 Quart Boxes
Powdered

Cheerios.. Chex.-Com.M (Rio::: or Wheat) Crispy Cri~ Country Com F1a1:.es Kix. Nabisco Cream of Wheat(Regular
Flavor}. Product 19. Jim Dandy Quick Grits (Iron Fortified). Minute 3 Brand Instant Oatmeal (Regular Flavor). Quak<:r Instant Grits (Regular Flavor). Tatal (Com),
Kellogg's Special K. Kelloggs's Com Flakes

Nine(9) Ounce Sizes and iV:>ove ONLY
Can Pun::hase More Than One(I) TypelBl1lnd ofCercal As Long k> The Amount Does Not Go Over The
Quantity on the Front ofThe Vo~

American (Sliced or Block). Cheddar (Block... Colby (Blocl:). Monterey Jack (Block).
Mozzarella (Block), Kraft Dduxc (Slic.:d &. Singly Wrap]Xd)

Nine(9) Ounce. Up to 16-Ounce [One (1) Pound] size Ol'\lJ... y

ORANGE (Least E.xp<:n.~ivc 8r,1I1d ONLY) GRAPEFRUIT (Least Expensive 8rand ONL)') GRAPE (Welch's or Juicy Juice) APPLE (Fb....orite,. Kroger. Lucky l.el.( Sen=
(Red Label Only). Sbf( Thifty M.u<!. ShurFinc.. White House ) OTIIER (Dole OrangeIPineapplc.. Oole OrangelPine:lpplel&ln:lna. Juicy Juice Chary. Juicy Juice Punch, Juicy Juice Tropical)

46-Ounce ("..ans or 12..ounce Frozen Cans ONLY

NOT ALLOWED Roamed Milk. Buttenni.lk. ()( Goat's Milk
Eight(8) Ounces or Less: Size Boxes
Chee..<;e Food.. Shredded or Dell Cheese. Two (2) Eight (8)
Ounce Packages for One(l) 16Ounce Package. or any cight (Ii)
Ounce or sm:tlkr package Juice Drinks. Fresh Squeezed
Juice Single Serving Sizes. Infant Jui<:es.. Juices with Sugar
Add";

EGGS (Gnde A!.&ge ONLY) DRIED PEASlBEANS PEANUTBUITER
INFANT FORMUlA
INFANT CEREAL (BoJ:SONLY)
TIJNA
CARROTS

Least Expensi...e Brand ONLY
Any Brand Without Flavoring Added Any Brcmd Withou1Jelly Added or Honey Spread
As Listed On The Front ofthe VoucbeT
Beech Nut. Gerber. Heinz
Least Expeosivc Brnnd ONLY W/lkr Packed ONLY Fresh.. Whole

One (I) Dozen

AnyOther SizclQuantity

One (I) Pound Size ONLY 18-Ounce Jar.i: ONLY

Any Other SizelQuantity

As Listed On Front ofthe VoucheT
Dry Ccreal in Eight (8) Ounce Sizes ONLY
6 ounce Cans ONLY

Any Type Not Listed On Front ofVoucber"
Any Baby Food in Jmsor Arty Dry Cereal with FnUt or Formula Aided
Tuna Packed in Oil

One (I) Pound Pre-SeaIcd pJastic B",ONLY

Bulk. frozen, Canned, Shredded. or Baby Carrots

FP-77

GA WIC PROCEDURES MANUAL FFY '96
Supplement Georgia WlC Program WlC APPROVED ALTERNATE FOOD LIST

Attachment FP-29

FOOD ITEM MILK (pasteurizoo) CEREAL
JUICE
CANNEDPEASI BEANS PEANUT BUITER INFANT FORMULA INFANT CEREAL (Boxes ONLY) roNA CARROTS

BRAND OR TYPE
UHT.1I.ffi..K.. Wbole or:zoA (lQSf.cxpensive lmmd) or AcidophiJus., Enjoy. La.ctaici 100.
Lactaid. or Dairy Ease
Chealos.. Chc:x..("..om.. Rice, or Wheat Crispy Critters. Countty Com Flakes, Kix.. Produd. 19. Total-Com., Nabisco Cream of Wheat (Rcgclar Flavor).
Jim Dandy Quid:. Grits (Iron Fonified). Minute 3 Brand Instant Oatmeal plus oat
Brnn (Rcgular Flavor), Harvest Instant Oatmeal (Regular Flavor) Quaker Instant Oatmeal (Regular Flavor)
Kellogg's Special K. Kellogg's ('.om Flakes
ORANGE: Least Expensive: Brand ONLY GRAPEFRUIT: Least Expensive Br.md
O!,-'LY APPLE: Flavorite. Kroger. Lucl..-y Leaf. Stall ShurFine. \\nitchousc. Thrifty Maid..
Seneca (Re.:! Label O}"'L Y) OTHERS: Dole OrangcIT'ineapp1e
Dole OraI"lge/?ineappleIBarnma Juicy Juice Cherry Juicy Juiec Punch JuiC)' Juice Tropical
Any Brand \l,;!hout Flavoring Added

CONTAIN'ERlPACKAGE SIZE 8 Ounce Box or '>S. Gallon Or Quart
ofLactosc Reduced Milk Nine(9) Ounce Size Can Purchase More than Onc(t)TypclBrand of Cereal as Long as the Amount Does Not Go over the Quantity on the
front ofthe Voucher
6 ounce can
15 OImCe can only

NOT ALLOWED Flavored Milk. Buttermilk. or
Qoat'sMilk 8 Ounoe of less size boxes
Juice Drink... Fresh Squeezed juice. InfanlJuicc. Juice .....ith
Sugar Added
Any other sizdquantity

Any Brand ~thout Jelly Added
OfHo~Spread
As listed on the front ofthe Voucher
Bee<:h Nut.. Gerber. Heinz
Least Expensive Br.lnd ONLY. Watcr Packed ONLY
Any Brand Without Flavoring Added

18 ounce jar only

kty othersizelquantity

As listed on front of Voucher Dry ('=I in 8 ounce size only
6 ounce cans only

Puly type not listed on front of thevoueh"
Any baby food in jars or any dry cereal with fruit or formulas
"""00
Tuna padccd in oil

15 ounce canned sliced. medium cut

FP-78

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-30

WIC APPROVED FORMULASIMEDICAL FOODS

Contract Standard:"d

MILK BASED

SOY BASED

Enfamil with Iron

Prosobee with Iron

Non-Contract Special/Hospital Basedb

Enfamil Premature 20 with iron Enfami! Premature 20 Enfamil Premature 24 with iron Enfami! Premature 24 Enfamil 24 with iron Enfamil 24 low iron Enfamil Human Milk Fortifier with iron Enfamil Human Milk Fortifier Similac 24 with iron Similac 24 Similac 27 (low iron) Similac PM 60/40

Similac Special Care 20 (low iron) Similac Special Care 24 with iron Similac Special Care 24 (low iron) Similac Natural Care (low iron) SMA 24 (low iron) SMA Premature 20 SMA Premature 24 SMA 24 with iron SMA 27 with iron

Non-Contract Special: a,~ d

Advera Alirnentum Altema Casec Citrisource Citrotein CriticareHN Deliver DeliverHCN DeliverHN Enfamil Low Iron

Ensure EnsureHN Ensure Plus Ensure Plus HN Ensure with Fiber Fibersource Fibersource HN Flavonex Glucerna Isomil DF Isomil SF

Isosource Isosource HN levity Kindercal Lipisorb Lofenalac Magnacal Maxamaid Maxamum MCT Meritene

Microlipid Moducal MSUDDiet NeocateOne Nutramigen Nutren l.0/l.5/2.0 NutriVent Osmolite Osrnolite HN Pediasure Pediasure with Fiber

FP-79

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-30 con't

Non-Contract Special (Continued):

Pcptamcn Pcptamcil Junior Phcnc:'\ ! Phene,2 Phenylfrec Polycose Portagen Precision HN
Prccision!S0tol:i<;
Precision LR

Prcgcstimil 20 Pregestimil24 Product 3200A Product 3200AB Product 3200K Product 80056 ProMod Prosobcc Low Iron Provitamin Pulll10carc
ReF

Reabiho" RcabiliJ.ll I{N Resource Resource Plus Simi lac Neocare SMA S-14 SMA S-29. S-44 Suplena
SU$CiCJ.lllC
SustJC<11 Pudding

Sustacal with Fibcr Sustagcn Tolere, Tramacal Travasorb Hepatic Travasorb Renal TwoCal HN Ultracal
Vit.1.1
Vivonc.\:

If a physician orders a product that is not on this list, contact the Office of Nutrition to determine if the item is authorized for distribution through the WIC Program.
b. Hospital based products may be acquired through the Office of Nutrition. See Attachment FP - 30.
c. Low iron or no iron fonnula may be indicated only for limited conditions. Low iron fonnulas may be indicated for clients with hemochromatosis, hemosiderosis, or iron storage disease, polycythemia, thalassemia, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis and those participants requiring frequent transfusions. Low iron formula is not authorizedfor colic, spitting up, vomiting, cramps, constipation, diarrhea,fussiness orfor partially breastfed infants/children. See FP- 8, 11, and 14.
d. Ready-to-feed fonnula may be indicated in limited documented cases such as: I). Unsanitary or restricted water supply; 2). Inadequate refiigeration; or 3). If the caregiver has a documented condition which inhibits the proper dilution of concentrate or powder fonnula. See FP- 8, 11, and 14.
FP-80

GA WIC PROCEDURES MANUAL FFY'96

Attachment FP-31

PROCUREMENT OF HOSPITAL BASED FORMULA

Hospital based infant formulas may be ordered by a physician (only) to meet the nutrition needs ofpretenn infants and children with special health care needs.
Generally these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Office of Nutrition (OON) or in rare instances through a local pharmacy (WIC Vendor). When acquiring a product through the OON use the following procedure:
I. District WlC Coordinator or designated staffwill fax to OON the following information (see attachment FP-20 cont'd):
a. Date b. Name of client c. Birth date d. Diagnosis c. Nam~ of f0I1llu13 1'. Manufacturer's name g. Amount offonnula requested, list as number of cases or total fluid ounces h. Type offormula, list as ready-to-feed, concentrate, powder I. Estimated time on formula j. Formula issue month k. Prescribing physician L Hospital discharged form m. Clinic contact person/telephone number n. District contact person/signature
2. Call OON to notuy of incoming fax
3. Document request for formula and distribution in participants health record.

Submit order(s) monthly. The total fluid ounces per order must not exceed the maximum monthly aUowance. County health departments should receive shipment within 5 working days.
Notify OON immediately ifan incorrect order is delivered, or ifthere is a change in the formnla order.
Only a complete case(s) may to returned by the OON to the formula company for credit.

FP-81

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-31 con't

PROCUREMENT OF HOSPITAL BASED FORMULA JANUARY 1994

1. TO BE COMPLETED BY DISTRICTILOCAL STAFF

Date

_

L Name ofWIC client

_

2. Birthdate

_

3. Diagnosis

_

4. Name of formula requested

_

5. Product number/manufacturer of fonnula

_

6. Amount offonnula requested

_

7. Type offonnula: ready to feed. concentration. powder. single use bottle, etc.

_

8. Estimated time on fonnula

_

9. Fonnuia issue month

_

10. Clinic contact person/phone no.

_

11. Address/telephone number to ship formula

~

_

12. Prescribing Physician

_

13. Hospital discharged from

_

14. District contact person

_

15. WlClNutrition Coordinator's signature

_

CALL OON AND FAX TO FRANCES COOK., OFFICE OF NUTRITION: (404) 657-2884, FAX:(404) 657-2886

n. TO BE COMPLETED BY OFFICE OF NUTRITION

1. Formula Cost of~s order (including price per case)

_

2. Date order placed to fonnula company

_

3. CliniclDistrict's account number

_

4. Contact person at formula company/phone no.

_

5. Anticipated date of delivery 6. OON Nutrition Consultant's signature

~__:_----------
_

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

_

FP-82

GA WIC PROCEDURES MANUAL FFY '96

Attachment FP-32

SUPPLEMENTAL FORMULA CONVERSION TABLE Caloric Displacement Method

Monthly RX

Maximum Cans of Formula Allowed ChildIWoman

*Moducal (13 oz. powder)

I can

28

32

2 cans

25

29

3 cans

23

27

4 cans

20

24

** Polycose (12.0 oz. powder)

I can

28

32

2 cans

25

29

3 cans

23

27

4 cans

20

24

*** MCT Oil (32 fl. oz. bottle)

1 bottle

17

21

2 bottles

3

7

Infant is allowed a maximum of 403 fl. oz. of concentrated formula per month.

ChildIWoman is allowed a maximum of 455 fl. oz. of concentrated formula per month.
* Moducal powder: 1 can contains 46 TBSP/l400 calories ** Polycose powder: I can contains 59 TBSP/1330 calories *** MCT Oil: 1 bottle contains 960 cc/64 TBSP17300 calories

3 teaspoons = 1 TBSP I fl. oz. = 30 cc 13 oz can standard concelllrated contract formula = 40 callfl. oz. 13 oz. can standard recollstituted contract formula = 20 callfl. oz.

FP-83

GA WIC PROCEDURES MANUAL FY '96

TABLE OF CONTENTS

I. Purpose............................................. NE-I

II. Definition........................................... NE-I

III. Goals.............................................. NE-I

IV. State Agency

NE-I

A. Nutrition Staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. NE-I

B. Nutrition Education Responsibilities

NE-2

C. Breastfeeding Promotion and Support Responsibilities . . . . . . . . . . . .. NE-3

V. Local Agency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. NE-5

A. Nutrition Staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. NE-5

B. Breastfeeding Coordinator
14 .1i~flEIIt{lr1t~i~[~~1

NE-5 .~

D. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. NE-6

I~ IBilBilB;rJl!

III

VI. Participant Nutrition Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. NE-7

A. Participant Nutrition Education

Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-7

ml(.ml.~I'(ti~llIlimqn

R

VII. Participant Referral To Other Agencies . . . . . . . . . . . . . . . . . . . . . . . . . NE-lO

A. Referrals

NE-IO

B. Documentation...................................... NE-II

VIII. Nutrition Education Materials

NE-ll

A. Criteria for Development and Use

NE-ll

B. Available Nutrition Education Materials

NE-ll

C. Procedures for Ordering Nutrition Education Materials

NE-12

GA WIC PROCEDURFS MANUAL FY '96

Attachments:

NE-I Format for Nutrition Education Plan

NE-13

NE-2 Nutrition Inservice Programs Attended by Local Professional Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-15

NE-3 Nutrition Inservice Programs Conducted by Local Professional Staff

NE-16

NE-4 District Nutrition Education Plan

NE-17

NE-5 District Nutrition Education Plan Update

NE-18

NE-6 Guidelines" for Paraprofessional Training . . . . . . . . . . . . . . . . . . . . . . . . NE-19

NE-7 WIC Maternal High Risk Criteria

NE-23

NE-8 Material Evaluation Form

NE-24

NE-9 Central Supply Requisition Form

NE-29

GA WIC PROCEDURES MANUAL FY '96
I. PIJRPOSE
This section of the Procedures Manual defines the concept of nutrition education; states the goals for nutrition education; and explains the requirements for providing-nutrition education to WlC participants.
II. DEFlNITIDN
"Nutrition Education" is a dynamic process by which individuals gain the understanding, skills, and motivation necessary to promote and protect their nutritional well-being through their food choices. Nutrition education shall be designed based on ethnic, cultural and geographic preferences and with consideration for language, edu~onal and environmental fuctors.
m. GfiALS.
Nutrition education for WlC Participants is designed to achieve two broad goals:
A. Emphasize the relationship between proper nutrition and good health, with emphasis on the nutritional needs of pregnant, breastfeeding and postpartum non-breastfeeding women, infants and children under five (5) years of age.
B. Assist the individual who is at nutritional risk in achieving a positive change in food habits, resulting in improved nutritional status and in the prevention of nutrition-related problems through optimal use of supplemental foods and other nutritious foods.
IV. STATE AGENCY
A. Nutrition Staff
The delegation of WlC nutrition education activities is vested within the Georgia Department of Human Resources, Division of Public Health, Family Health Section, Office of Nutrition.
The nutrition education component of the WlC Program is carried out under the direction of a qualified nutritionist (M.A., M.S. or M.P.H., and R.D. or eligible for registration). The responsibilities of this person are to plan, direct and coordinate the nutrition education component of the WlC Program.
A qualified nutritionist (M.A., M.S., or M.P.H., and R.D. or eligible for registration) is designated as the State Breastfeeding Coordinator. The responsibilities of this person are to plan, direct and coordinate the breastfeeding promotion and
NE- I

GA WIC PROCEDURES MANUAL FY '96
support component of the WIC Program. Nutrition Program Consultants in the Office of Nutrition are assigned to districts/units to function as a resource for facilitating the State's efforts in strengthening and integrating MCR and WIC nutrition services. Current staff assignments are available from the Office of Nutrition.
B. Nutrition Education Responsibilities
The following are 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 reports~
4. Evaluate nutrition services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for (CPA's) and paraprofessional 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 special problems and emerging issues in nutrition.
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 persons 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 offered to all adult participants and to parents or caretakers of infant or child participants, as well as child participants whenever possible.
9. Perform and document evaluation of nutrition education activities for each local agency on an annual basis. The evaluation shall include an assessment of participant's views concerning the effectiveness of the nutrition education which they received.
NE-2

GA WlC PROCEDURES MANUAL FY '96
10. Establish standards for participant contact that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.
C. Breastfeeding Promotion and Support Responsibilities
The following are the State agency responsibilities for breastfeeding education, promotion and support:
1. Develop, implement and evaluate the State Breastfeeding Education, Promotion and Support Plan. Periodically review and evaluate and make appropriate revisions as necessary.
2. Develop guidelines for local agency Breastfeeding Education, Promotion and Support Plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency Breastfeeding Education, Promotion and Support plans on a periodic basis through on-site visits and reports.
4. Evaluate breastfeeding education, promotion and support services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for (CPA's) and paraprofessional staff at local clinics. Training and technical assistance provides WIC competent professional authorities with current information on the management of normal breastfeeding issues and special problems in lactation.
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 proportion of the population needs the information in a language other than English, considering the size and concentration of such population and, where possible, the reading level of participants.
7. Coordinate WIC breastfeeding education, promotion 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.
NE-3

GA WIC PROCEDURFS MANUAL FY '96
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 education, prometion and support activities for each local agency on an annual basis. The evaluation shall include an assessment of participant's views concerning the effectiveness of the education which they received.
10. Establish standards for participant contact that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.
12. Establish breastfeeding promotion and support standards which 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 task-appropriate 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 and suppOrt activities during the prenatal and postpartum periods.
NE-4

GA WIC PROCEDURES MANUAL FY '96
v. IDCAI. AGENCY
A. 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 Program Consultant or Principal Nutritionist. 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 nutritional risk criteria.
2. Nutrition positions should be appropriately classified according to the Merit System class specification for nutrition personnel. The Senior Nutritionist, or Nutritionist Merit System class specifications should be used for nutritionists providing direct client nutrition services, and incumbents should receive supervision from a higher level public health nutritionist.
3. The Merit System class specification for nutrition personnel and qualifications and compensation levels are available on request from the Merit System of Personnel Administration or from the Office of Nutrition.
B. Breastfeeding Coordinator
Each local agency must designate a staff person to coordinate breastfeeding promotion and support activities. It is recommended that the breastfeeding coordinator position be filled by a qualified nutritionist, nurse or health educator.
C. 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, to 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.
NE-5

GA WIe PROCEDURES MANUAL FY '96
2. Provide in-service training and technical assistance for competent professional authorities (CPA's) and paraprofessional staff at local clinics.
D. Training 1. Orientation Nutrition staff should attend the three (3) levels of the Competency Based Skills Workshops during their first twenty-four (24) months of employment. The CQmpetency Based Skills Workshops are conducted by the Office of Nutrition. These workshops provide WlC competent professional authorities with current information on the nutritional management of normal and high risk prenatals, infants, children, and adolescents; breastfeeding management in normal and special situations; and an update on special problems and emerging issues in nutrition. Presenters are nationally known and provide state of the art practice methods. 2. Continuing Education a. All competent professional authorities are encouraged to attend local, state or national workshops for meetings for the purpose of developing and updating skills and knowledge in nutrition and lactation management. 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. The file should include the name and title of the participant and the title and date of the workshop (see Attachments NE-2 and NE-3 for recommended forms).
NE-6

GA WIC PROCEDURES MANUAL FY '96

E. Nutrition Education Plan

1. Biennial Nutrition Education A two (2) year Nutrition EducailltiiioiinjP]ijjlan~~ to the Office of Nutrition by "

m~11I;jrI121!~~ must be submitted
of the appropriate year.

a. The local agency Nutrition Education Plan must include:

I) Needs assessment for each objective 2) Each objective in behavioral terms 3) Evaluation design for each objective 5) Action steps, including activities and methods for each objective 6) Resources to conduct each objective 7) Milestone of activities for each objective

b. Plans must relate to nutrition education services. c. The Nutrition Education Plan should address the following areas at a
minimum: nutrition education contacts and nutrition education materials.

2. Nutrition Education Plan Update

The update is a progress report and must be submitted to the Office of Nutrition by December 1 of each year and should include the following:

I) Brief description of milestones accomplished 2) Revision, deletion, and/or addition of objectives 3) Revision, deletion, and/or addition of action steps

3. Format and Form - See Attachments NE-I, NE-4 and NE-5.

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 during each six (6) month certification period. 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.

NE-7

GA WIC PROCEDURES MANUAL FY '96
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. The Nutrition Guidelines for Practice are the established guide for nutrition education contacts.
4. All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons. As recommended in the Nutrition Guidelines for Practice, encouragement to breastfeed should continue throughout the prenatal period. In addition, information must be offered on WIC benefits for breastfeeding women. This information should include the following:
a. Breastfeeding women are at a higher level in the priority system than nonbreastfeeding postpartum women, and are more likely to be serviced than these women when local agencies do not have the resources to serve all qualified individuals.
b. Breastfeeding women may receive WIC benefits for up to I year while nonbreastfeeding women are eligible for only 6 months postpartum.
c. WIC offers a greater variety and quantity of food to breastfeeding participants that to non-breastfeeding, postpartum participants.
5. Nutrition education contacts must be provided by a nutritionist, registered dietitian, registered and licensed practical nurses, physician, physician's assistant, or other certified health professional that has been trained by the State or local agency. Paraprofessionals can provide nutrition education contacts when appropriate nutrition education training has been received. The training plan must be approved by the Office of Nutrition. (See Attachment NE-6 for the Guidelines for Paraprofessional Training and list of items to be submitted for approval.)
6. Incorporation of drug and other harmful substance abuse information into nutrition education as required.
7. An individual nutrition care plan should be developed for a participant based on the need for such plan as determined by the competent professional authority. The Nutrition Care Plan should be written in the progress notes, preferably using the SOAP (Subjective - Objective - Assessment - Plan) note format (see Attachment NE-7 for an example of a SOAP note).
8. A lesson plan must be developed when group classes are used to provide the
NE-8

GA WIC PROCEDURES MANUAL FY '96
nutrition education contact. Lesson plans 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.
9. 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
I. All 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 should be documented (e.g., introduce food singularly; portion sizes for the 2-3 year old; ways to increase fluid intake).
b. The POMR (Eroblem 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 (see Attachments NE-7 for SOAP Note Format).
c. Group Nutrition Education Contacts may be documented with the
lluIi participant's signature on a class attendance sheet or voucher register
class roster which contains the lesson objective(s) and the original signature of the staff conducting the class A description of the district's method of documentation must be submitted for approval prior to implementation. 2. Documentation of encouragement to breastfeed should include all aspects of breastfeeding discussed with the participant (e.g., barriers to breastfeeding; emotional and nutritional advantages of breastfeeding; positioning).
3. 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.
NE-9

GA WIC PROCEDURES MANUAL FY '96

2. Documentation of encouragement to breastfeed should include all aspects of breastfeeding discussed with the participant (e.g., barriers to breastfeeding; emotional and nutritional advantages of breastfeeding; positioning).

3. 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.

VB. PARTlCJPANTREFERRAI.TOOTHER AGENCIES

Participants must be assessed for referrals during each certification appointment.

A. Referrals

1. Participants who appear to be eligible for the Food Stamp Program and Aid to Families with Dependent Children (AFDC) shall be informed of these programs and 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:

Maternal Health Programs

Child Health programs

High Risk Pregnancy Program Family Planning Program Sexually Transmitted Disease

Children's Medical Services Immunization Program Lead Screening Program EPSDT Dental Health Program

Assistance programs

Communjty Resources

Food Stamps Medicaid Right from the Start AFDC Headstart

Aids Program Private Physician Mental Health and Substance Abuse Program

NE- 10

GA WIC PROCEDURES MANUAL FY '96
4. Prenatal or breastfeeding participants needing additional breastfeeding infonnation, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.
B. Documentation
Referrals to and enrollment in other health services and programs must be documented in participant's health record. A decision not to refer or a refusal by the participant must also be documented.
VITI. NUTRITION EDUCATION MATERIAl S
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.
The Office of Nutrition is 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 submitted to the Office of Nutrition each fiscal year.
3. All nutrition education materials used must accurately reflect current documented scientific knowledge of nutrition.
4. Reading levels should be evaluated and appropriate for the target audience.
5. The Office of Nutrition reserves the right to disapprove the use of nutrition education materials if it determines them to be inappropriate.
6. Materials must be prepared to meet needs of the specific population group to be served, including migrants. Consideration must be given to cultural and language needs of clients.
7. If a local agency develops material that may be applicable Statewide, the Office of Nutrition will seek approval from the local agency to duplicate the materials.
8. See Materials Evaluation Fonn for guidance. (Attachment NE-8)
B. Available Nutrition Education Materials
A catalog of nutrition education materials can be obtained from the Office of
NE- 11

GA WIC PROCEDURES MANUAL FY '96 Nutrition. Other available materials include slides, audio cassettes, video tapes, teaching aids, and displays. Districts are encouraged to order and utilize Office of Nutrition materials, prior to ordering materials prepared by pharmaceutical or other companies.
C. Procedure for Ordering Nutrition Education Materials 1. All counties/clinic sites must order WIC nutrition education materials through their district office. 2. All education materials must be ordered on a requisition form #5014 (Attachment NE-9) by the district WIC Coordinator for all local WIC clinics sent to the Office of Nutrition. This requisition will be forwarded to Central Supply by the Office of Nutrition.
NE- 12

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-1

FORMAT FOR NUTRITION EDUCATION PLAN

TITLE PAGE
District/Unit Time Period of Plan Name(s) and Title(s) of Person(s) Preparing Plan

BODY OF PLAN

Needs Assessment:

A statement of the problem. It tells why something should be done. Include facts and/or statistics.

Objectives:

Should begin with "To... " and include an action v~rb; desired results or outcome; a target group; and a time frame of completion date.

Evaluation Design:

Process of determining the extent to which the outcome is commensurate with State objective.

Action Steps/Activities/Methods:

Tasks that relate directly to the achievement of goals and objectives as identified.

Resources:

Staff, facilities (space available, etc.), materials and technical assistance.

Milestones of Activities:

Target dates for accomplishment of key activities.

Attachment NE-1

Examples of behavioral objectives are for the following areas:

1. Breastfeeding: Increase the incidence of breastfeeding among WIC participants from (xx)% to (xx)% and six month duration from (xx)% to (xx)% by (month) (date), I99(x).

NE-13

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-l

2. Nutrition Education Contacts: Increase the percentage of pertinent nutrition education contacts provided to WIC participants from (xx)% to (xx)% by (month) (date), 199(x).
3. Nutrition Education Materials: Provide to all WIC participants only nutrition education materials appropriate to participants' culture, literacy level and WIC classification.
4. Staff Training: By (month) (da,te), 199(x), provide training to staff responsible for WIC in provision of - services - certification - food package assignment, and/or - nutrition education.
5. High Risk: Provide consultation to WIC participants identified to be at high risk through the WIC Maternal/Child High Risk Criteria.

NE-14

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-2

NIITRmON TNSERVTCE pROGR AMS ATIENDED BY lOCAl PROFESSIONAl STAFF

DATE

NAME & TITLE OF PARTICIPANTS

TITLE OF WORKSHOP

FUNDING SOURCE
-~

NE-15

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-3

NIITRmQN TNSERVTCE pROGRAMS mNDUCTED By T OCAT PRQFFSSTONAL STAEE

DATE

TITLE AND WORKSHOP

INSTRUCTOR

NUMBER OF LOCAL STAFF ATTENDED BY: DISCIPLINE
NURSES NUTRITIONISTS OTHER

-,

NE-16

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-4

DISTRICT NUTRITION EIDICATION

DISTRICT

NUTRITION EDUCATION PLAN

FFY

DISTRICT NUTRITION COORDINATOR:

NEEDS ASSESSMENT:

- .-
OBJECTIVE:

EVALUATION DESIGN:

ACTION STEPS/ACTIVITIES/METHODS RESOURCES

MILESTONE OF ACTIVITIES

NE- 17

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-5

NUTRITION EDUCATION PLAN UPDATE

DISTRICT

_

FFY __

District Nutrition Coordinator:

_

Date:

_

Objective:

Brief Description of Action Steps!Activities Accomplished:

Revision Deletion and/or Addition of Objective:

Revision Deletion and/or Addition of Action Steps for Objective:

NE-18

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-6

. GIIJDEI.INFS FOR PARAPROFFSSIONAI. TRAINING Qualjfications for Paraprofessionals Who can he trained
1. WlC clerical staff and Health Services Technicians. 2. Expanded Food and Nutrition Education Program (EFNEP) agents. 3. Volunteers with a background in Home Economics, Nutrition, Medical Science
and Health Education. 4. Nursing students who have taken at least one (1) nutrition course. 5. University students who have done nutrition/health coursework. CompeteD.ries for Paraprofessionals
Basic WC Program Knowledge. The WlC paraprofessional 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 WlC Program. 4. Identify the district WlC staff, including the district nutrition consultant, and
where to locate the district WlC office(address and phone number). 5. Locate: (a) the local WlC clinic policies and procedures; (b) list of local area
WIC vendors; (c) personal reference book (if one is developed); and (d) USDA rules and regulations or Georgia WC Program procedures Manual policies relating to supplemental foods and nutrition education. 6. Describe the process of how a WlC participant obtains WlC foods. 7. List the various WlC approved foods.
8. List notification requirements.

NE-19

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-6 cont'd

9. Demonstrate a thorough knowledge of individual lesson plans and content, as outlined by the district nutrition coordinator or designee. The paraprofessional should score ninety percent (90%) or above on the written test.
Communication Skills. The WlC paraprofessional will be able to:
1. Demonstrate each of the following factors in a participant interview or group class:
-Introducing of self -Explaining purpose of class/contact -Working within a given timeframe -Listening -Using open-ended questions -Being non-judgmental -Using simple language -Conveying sincere interest -C.onveying positive body language and attitude
2. Identify problems, during the individual contact or class, which are WlC, health, or staff-participant relationship oriented.
Referral Skills. The WlC paraprofessional will be able to:
1. Refer problems encountered during the class/individual contact to appropriate personnel.
2. Refer medical and nutrition related problems to the appropriate professional, as written in the lesson plans.
Requirements for TraiuinglContjnJ]ing EdJlcatjon
Secondary nutrition education contacts can be provided within the following parameters:
I. A training session must be completed,
2. The test and clinic observation must be completed for each topic area, and
3. Nutrition information given to participants must be limited to that received in the training sessions (topic area) by the paraprofessional.

NE-20

GA WIC PROCEDURES MANUAL FY '96
Paraprofessionals must receive at least 12 hours of continuing education per year. These hours can be attained through attendance of the Annual Competency Based Skills Workshop for paraprofessionals, provided by the Office of Nutrition.
1. Other nutrition conferences/workshops.
2. Other health conferences with a nutrition component, covering at least two (2) hours of nutrition information.
Nutrition infonnation being used to fulfill the continuing education requirement must be pertinent to the areas of nutrition education in which the paraprofessional has received or is receiving training.
Parameters for Paraprofessionals
Paraprofessionals will be trained to provide very specific and limited nutrition information to WlC participants. Information will be limited to that learned in training. Referrals will be made, based on guidance in lesson plans training manual, and/or questions beyond the scope of the training received by the paraprofessional.
Evaluation Component
Evaluation of the paraprofessional includes the following:
1. The paraprofessional must score the required percentage on a test for each topic area, before being able to proceed to the next step.
2. The paraprofessional must observe a professional providing secondary nutrition education contacts for at least one (1) clinic day, before being able to provide these her/himself.
3. The paraprofessional must be observed conducting at least three (3) secondary nutrition education contacts before being able to do so routinely.
4. The paraprofessional's immediate supervisor must be readily accessible to assist the paraprofessional with problems.
5. The district nutrition coordinator (or designee) will conduct quarterly record reviews and observe the paraprofessional providing secondary nutrition education contacts.
6. The district nutrition coordinator (or designee) will be available to provide technical supervision and to act as a resource.
NE-2l

GA WIC PROCEDURES MANUAL FY '96
PARAPROFESSIONAL TRAINING PLAN CHECKLIST FOR ITEMS TO SUBMIT FOR APPROVAL
Training Plan: I.esson Plans for use in training paraprofessionals, including post-tests. May be submitted on an on-going basis.
EvalJJ3tion Component
Plan for paraprofessional to observe professional(s) providing secondary nutrition contacts. Plan for nutrition coordinator (or designee) to observe paraprofessional(s) providing secondary nutrition education contacts. Plan for conducting quarterly chart reviews and observation of paraprofessional(s). I.esson plans for use by paraprofessional(s) in providing secondary nutrition education contacts - group class or individual counseling. Documentation Procedures to be used by paraprofessionals.
Additional Information: Name(s) of paraprofessional(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.
NE-22

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-7

WIC MATERNAL HIGH RISK CRITERIA
Any WIC prenatI1, breastfeeding or non-breastfeeding postpartum who has the following high risk factors must receive nutritional counseling specific to their nutritional condition and to the nutritional problems identified in their diet as reflected in an individual care plan.
1. Pre-pregnancy/postpartum weight less than or equal to 10 percent below the standard weight for their height.
2. Inadequate prenatal weight gain of less than two pounds in one month, during the second or third trimester.
3. Hemoglobin or hematocrit at treatment level.
4. Multiple gestation current or most recent pregnancy.
5. IDV positive/AIDS
6. Presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or nurse practitioner.
WIC IDGH RISK FACTORS FOR INFANTS AND CHILDREN
WIC infants and children who have the following high risk factors must receive more individual nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet as reflected in an individual care plan.
1. Weight for length/height less than or equal to 5th percentile.
2. Length/height for age less than or equal to 5th percentile.
3. Weight for height pattern that has dropped two or more percentile channels in either 6 months or on more than one occasion in 12 months.
4. Hemoglobin or hematocrit at treatment level.
5. IDV positive/AIDS
6. Presence of any disease or condition affecting nutritional status that requires a therapeutic diet as by a physician or nurse practitioner.
7. Physical or developmental disabilities resulting in special feeding problems.
NE-23

GA WIC PROCEDURFS MANUAL FY '96

Attachment NE-8

MATERIAL EVAIJ!ATION FORM
~~~:~~:~ ~~:._/_T_i_t_l_e::::::::::::::::::.JD"'a"'ti:"e=-"R-=e-=c-=e"'i-::v:::e:::d~-=--=--=--:"-_-_-_-_-~~------

EVALUATION CRITERIA

SPONSOR BIAS OR PROMOTION
*Product name not visible.

CONTENT * Non-discrimination clause present.

* Accurate and up-to-date.

* outcome
-no more than 3 objectives

-does not promote undesirable behavior

* Scope
-topics deeme? necessary

-useful and relevant to target audience
* Appropriate for target audiences lives
and environment

* Clear purpose of material.
* Organization -main ideas are clear

-smooth flow of material

* Learning experiences
-seeks learner involvement

-appropriate knowledge/skill level

-suggests further learning

* Summarization of ideas

*

References usable

are

accurate,

up-to-date

and

MINIMALLY ACCEPTABLE

ADEQUATE SUPERIOR

-,

NE-24

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-8 cont'd

EVALUATION CRITERIA
LANGUAGE USAGE * Reading level appropriate for audience
(use SMOG)
* Few technical terms used with definitions
provided.
* Style -personal
-few instances of negative wording -respectful non-condescending tone -sentences ar~ simple, short and specific
* Use of words is consistent STEREOTYPING * Appropriate role models * Minority representation
-presented in a factual manner -variety in roles, occupations, and values
* Lifestyle/Culture differences are reflected

MINIMALLY ACCEPTABLE

ADEQUATE SUPERIOR
-~

NE-25

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-8 cont'd

EVALUATION CRITERIA
FORMAT
* Paper quality is acceptable for intended use * Print
-style acceptable
-size appropriate * Topic headings/Typographic cuing
* Line width and spacing * Placement and use of illustrations * Placement and use of charts, tables, graphs * COlor
-good choice
-good quality * Pages
-appropriate length
-face to face
* Overall visual appearance is pleasing * Quality of sound track is good

MINIMALLY ACCEPTABLE

ADEQUATE SUPERIOR
-

NE-26

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-8 cont'd

other Areas to be Considered Prior to Purchase

EVALUATION CRITERIA
COST
* Original
-material cost -shipping/handling -discount for multiples -easy to obtain -time to obtain
* Replacement
-reasonable work life (durability) -predisposed to obsolescence -ease of repair (include shipping/handling) -cost of replacement * Duplication -allowable/legal -cost of duplication

MINIMALLY ADEQUATE SUPERIOR ACCEPTABLE

NE-27

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-8 cont'd

EVALUATION CRITERIA

MINIMALLY ADEQUATE SUPERIOR ACCEPTABLE

VIEWING/USAGE
* Space
-available for viewing/use of materials

-available storage

* East to use
-staff

-,

-audience/patient

*Geared for -group classes

-individual counseling/use

-waiting room" use

* Is there an easier, more efficient way to stimulate the same behavior?
RECOMMENDATIONS

SIGNATURE OF EVALUATOR'-

Title

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.

NE-28

GA WIC PROCEDURES MANUAL FY '96

Attachment NE-9

CENTRAL SUPPLY REQUISITION FORM

TO BE TYPEWRITTEN ONLY

Georgia Department of' Human Resources
CENTRAL SUPPLY/FORMS DESIGN 1150 Murphy-Avenue, S.W. Suite J
Atlanta, Georgia 30310-3801

INVOICE NO.

INVOICE NO.

SEND TO~:

---,.,.,.-_---:---:-:=---,

_

(Name of Office)

(Name of Divisoin)

(Street Address or State Office Room Number)

(City)

(State)

(Zip Code)

COUNTY: DATE:

(Name)

(Number)

W-W-Uj

ORGANIZATION

CODE:

W-u.lJ-LLLJ-u.lJ

DIVISION ID

NUMBER:

UlJ

BO BACKORDER-DO NOT REORDER

R

EXPLANATION C QUANTITY CUT/PLEASE REORDER OF CODES

N NOT STORED IN CENTRAL SUPPLY V

REFERRED

L REPRODUCE LOCALLY D DISCONTINUED

VOID, PREVIOUSLY SHIPPED

CHECK ONE:: [ ] Office Supply [ ] forms Supply

Form No./Item No.

Unit of Issue

QUllntity

(Do Not Put Office Supplies and Forms on Same Requisitoln)
De15cription

(NO'J:E) PHONE AND lUlND fiBI7:'ZEN BEQUISI7:IONS ~
N07: BE ACCE1?'J:ED

FOR CEN'1!IIAL SU1?PLr USE
ONLr

f-J::o.DJ4-.Jl.E===:L.-l FOR CENrnAL SUPPLY USE ONLY UPS {3-22-475} E'aree Post E'reight

ORDERED BY: -"':"(""Na-m-e"':"j--------------1C":T"':"i-tl:-e-:.}--------

Telephone:

(Gist No.)

(Are.il Code)

(Phone No.)

FILLED BY PACKAGED BY DATE SHIPPED

FOr!ll son (ll.ev.S-92)

= SEND ALL COPIES 7:0

SU1?PLr

NE-29

TABLE OF CONTENTS

A. Definitions B. Season

.

....................... .sP-I

.

...................... .sP-!!,

Transfer of Certification

.

~! Processing Standards

~l Income Eligibility

. .sP-!!,
........ .sP-i . . . .sP-~

Outreach and Referral Communication Network Food Delivery

. .

.... .sP-$
. .sP-~ ..sP~

Reporting

.

. . .sP4l,

Fair Hearing

. . . . . . . . . . . . . . . . . . . . . .sP4l,

Services'For ~N!t!~l~.l~~lll:itll~.I~Applicants/Participant.s. . . ..... .sP~

Applicants/Participants Residing In Institutions Which Serve Meals .....

........... .sP-

Applicants/Participants Residing In Temporary Locations

. ........... .sP-{'!

IV. Services For Other Special Populations

.

A. Non-English Speaking Populations

B. Refugees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.sP-$ .sP~~ . .sP-~

C. Native Americans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. .sP-g

E. Interpreter Services (Hearing-Impaired)

.sP-g

Attachments:

SP-I

Migrant Health Program

SP-2

Migrant Education Stafl7Five Regional Offices

....... sp.-li
. ........ Sp.-'111

SP-3

Telamon Corporation (Migrant and Seasonal Farmworkers

Association, Inc.)

.

........... sp.-ll

SP-4

Interpreter Services Through Georgia

Refugee Health Program

SP-5

Georgia Interpreter Services for the Hearing Impaired

sp.~11 .sP.j;t~

GA WIC PROCEDURES MANUAL FY '96
IT. SERVICES FOR1MIGRANTS
A. Definition
Migrants are individuals (and his/her family) whose main employment is in agriculture seasonally, who has been employed within the last twenty-four (24) months; and has established for such employment a temporary residence.
SP - 1

GA WIC PROCEDURES MANUAL FY '96
Seasonal farmworkers employed in agriculture whose residence Is Not temporary Are Not considered migrant workers. B. Season
Migrants work in Georgia all year round. The heaviest concentration of migrant activity in Georgia is located in the following districts:
1. Albany 2. Columbus 3. Macon 4. Valdosta 5. Waycross Migrant movement has also been reported in the following districts: 1. Athens 2. Augusta 3. Dublin 4. Gainesville 5. LaGrange 6. Rome C. Certification
D. Transfer of Certification Any migrant who presents a current Verification of Certification (VOC) card must be automatically placed on the local WIC Program, even if a waiting list exists. Regardless ofwhether the VOC card is entirely filled out, the receiving local agency
SP - 2

GA WIC PROCEDURES MANUAL FY '96 must accept the transfer of certification as long as the certification is still valid and the card contains the participant's name and certification date. A copy or the original VOC card must be placed in the participant's file/record. At certification, a new Georgia VOC card should be issued. The local agency must contact the original certifying agency to obtain the necessary information to complete the VOC card. If the local agency is unable to contact the original certifying agency, all pertinent information should be provided to the State agency for follow up. Every effort should be made to ensure that migrants are served in the most efficient way possible. All migrant farmworkers are to be issued VOC cards.
E. Processing Standards Migrant farmworker families will be notified of their eligibility or ineligibility within ten calendar days oftheir first request for Program benefits (initial contact date).
F. Income Eligibility Income eligibility is valid for instream migrant farmworkers and their families for a period of 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 instream area during the agricultural season.
G. Outreach and Referral Each local agency should decide whether evening clinics or certification at migrant camps are necessary. This decision should be based on migrant outreach and consultation with migrant organizations. All services necessary to serve migrant populations should be implemented. WIC services and the staff serving migrants shall make every effort to provide access to health services for migrants and their families.
H. Communication Network
SP - 3

GA WIC PROCEDURES MANUAL FY '96
I. Food Delivery
Migrants frequently remain in a local area for very short periods. It is essential that their receipt ofWIC foods be expedited by any means possible. Vouchers must be issued on the same day the migrant participant is certified.
When a migrant presents vouchers from another state's WIC Program, the clinic should void and destroy them and issue Georgia WIC replacement vouchers. When a migrant presents vouchers from another clinic in Georgia, the staff should instruct the migrant to redeem them if they bear a valid issue date.
J. Reporting
The number of migrants participating in the Georgia WIC Program is reported on the Racial/Ethnic Participation Report generated by the ADP Contractor each month. Therefore, it is very important that "Y or N" be filled in on each Turnaround Document (TAD) for migrants. . ant activi and e enditure e
ed

K. Fair Hearing

In the event that a migrant family member requests a fair hearing, the local agency should act as quickly as possible to expedite the procedures. The local agency should attempt to find out how long the migrant will be in the area and should convey this information to the Fair Hearings Unit and the State WIC Office.

m. SERVICES FOR "~IiIIf.Iif;_Il:t!:'~

}APPLICANTSI

PARTICIPANTS

SP-4

GA WIC PROCEDURES MANUAL FY '96
WIC Program applicants/participants who reside in institutions which serve meals may participate in the Georgia WIC Program. The "institution" may be a permanent or temporary residence such as homeless shelter, group home, shelter rofbattered women, etc. An outline ofthe conditions under which eligible persons affiliated with institutions may participate in the Georgia WIC Program during certification and participation are: 1. When determining income eligibility, the family size of the institutionalized
person or unit ofrelated persons, i.e. a mother and her children in a temporary shelter for battered women, does not include other residents of the institution. Income of the institutionalized person is also separate from the general revenues of the institution. 2. The institution must not accrue financial or in-kind benefit from a person's participation in WIC, e.g. by transferring WIC foods provided to persons in institutions to the institution's own general inventories or reducing the quantity offood provided to WIC participants. 3. Food items purchased with WIC vouchers must not be used in communal feeding. IfWIC foods were used in the institution's communal food service, they would reduce institutional food costs, but would not enhance the participant's diet to the degree intended. 4. No institutional constraints may be placed on the ability of the WIC participant to partake of supplemental foods and all associated WIC services made available for participants by the local WIC agency. Participants must have full, free, and direct access to all Program benefits and services available.
SP - 5

GA WIC PROCEDURES MANUAL FY '96
These conditions have been established to ensure that:
The program benefits the participant rather than the institution, and;
The person participates in WIC in the same 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 name of the institution the applicant/participant resides in.
2. Conditions addressed in Section II.A. 2, 3, and 4 in the above information 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.
C. ApplicantslParticipants Residing in Temporary Locations
Individuals who have lost their usual (or primary) place of residence may be temporarily relocated. Local WIC Programs are responsible for ensuring accessibility ofWIC services to this population. Individuals in this category include, but are not limited to: Battered women and their children in temporary shelters; homeless persons who may be residing in a vehicle, park, hallway, doorstep, sidewalk, abandoned buildin teenagers in a
Individuals who reside in a temporary location 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 and all WIC procedures should be thoroughly explained.
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 area ofthe clinic where they last received vouchers, they should be transferred into the clinic nearest to them and issued vouchers.
Due to the nature oftheir temporary residence, cooking facilities, refrigeration, and acceptable storage areas may not be available. Therefore, special consideration
SP - 6

GA WIC PROCEDURES MANUAL FY '96 IDllst be given to the issuance of supplemental food packages in order for them 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. Tailor the food package by using alternate 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 milk powder. 3. Offer ready-to-feed or powdered formula when sanitation or storage is a problem. Education: Educate the participant about the following regarding the use and storage of food:
I. Discuss spreading out redemption ofvouchers over the 4-week period. 2. Offer information on food storage and sanitation, when applicable.
Outreach: Local agencies should contact and distribute outreach materials to other agencies offering services to persons who reside in temporary locations. Referral:
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 your agency. These high risk individuals must be referred to appropriate health and human service agencies within your area, such as:
Local welfare!AFDC client assistance services Food pantries/meal programs Local shelters Food Stamps Legal services
SP - 7

GA WIC PROCEDURES MANUAL FY '96 IV. SERVICES FOR OTHER SPECIAL POPULATIONS A. Non-English Speaking Populations
In areas where a substantial number ofpersons do not speak English, local agencies shall cany 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 which serve non-English speaking persons. A variety of Spanish nutrition education materials, including slide/tape presentations and posters, are available through the State WIC Office, the Office of Nutrition (see Administration Section, Attachment AD-5).

B. Refugees

Ith the significant number of refugees, such as

Cuban, Haitian,

d Vietnamese, in Georgia, every effort will be made to

ensure service is extended to these populations. Aliens (legal and illegal) are eligible

to apply for participation in the program on the same basis as United States

Citizens.

SP - 8

GA WIC PROCEDURES MANUAL FY '96 C. Native Americans The WIC Program should make every effort to locate and enrol! all eligible Native Americans. D.
E. Interpreter Services (Hearing-Impaired) The WIC Program must assist Hearing-Impaired individuals/families in receiving WIC Services. Interpreters are available through the State Rehabilitation Program. (see Attachment SP-4)
SP - 9

GA WIC PROCEDURES MANUAL FY '96
GEORGIA MIGRANT HEALTH PROGRAM State Office of Rural Health
2 Peachtree Street, N.W., Sixth Floor Atlanta, GA 30303 (404) 657-6620
Barbara Bruno, Director

Attachment SP-l

Health Director

Migrant Program Staff

Columbus

Mary Arme Shepherd, FNP & Project Coordinator P.O. Box 346 Ellaville, GA 31806 (912)937-2308

Macon

Helen Hudson, Project Coordinator P.O. Box 1149 Ft. Valley, GA31030 (912) 825-6975

Valdosta

Russell Paulk, Program Manager P.O. Box 5147 Valdosta, GA31601 (912) 333-5290

Waycross Albany

Frank Stilp, FNP & Project Coordinator P.O. Box 255 Metter, GA 30439 (912) 685-5765
Gail Womble, Adult Health Director 1109 N. Jackson Street Albany, GA 31708 (912) 430-4575

County Served
Schley Sumter Macon Taylor Crisn
Crawford Peach

Contact Person

Phone Number

Vicki Wilder LunedaBmwn Brenda Oglesby
- Dorothy Brown
Alicia Brown ~
Linda Houch Bertha Ashley

(912) 937-2308 (912) 924-3637 (912)- 472-8121 (912) 862-5628 (912) 276-2680
(912) 836-3167 (912) 825-6939

Brooks Cook Echols Lowndes Hahira Lake Park Tift
Atkinson Candler Coffee Tatlna11 Toombs
Colquitt

Norma Jean Johnson Velma Bennett Rudene Moulton
Evelyn Wilkerson Joanne Scoggins Cindy Middleton
Pat Evans
Peggy James Diane Bryant Sandy Bradford Angela Harden Mamie Thomas
Pat Singletary

(912) 263-7585 (912) 896-3030 (912) 559-5103 (912) 245-2314 (912) 744-2665 (912) 559-6470 (912) 386-8373
(912) 422-3332 (912) 685-5765 (912) 383-4450 (912) 557-6791 (912) 526-8108
(912) 985-6805

SP - 10

GA WIC PROCEDURES MANUAL FY '96
MIGRANT EDUCATION STAFF
Ms. Michelle Rosinek, Consultant Georgia Migrant Education Program
State Department ofEducation Twin Towers East - 1958 Atlanta, Georgia 30334 404/656-4995

Attachment SP-2

REGIONAL OFFICES
Chattahoochee Flint Regional Education Service Agency P.O. Box 588
Americus,Gi\ 31709 912/928-1290

Migrant Education Association Live Oak
P.O. Box 826 Statesboro, Gi\ 30458
912/489-8601

Peachtree Migrant Education Association P.O. Box 2036
Tifton, Georgia 31794 912/382-5811

Piedmont Migrant Education Association 3536 East Hall Road
Gainesville, GA 30507 404/536-5717

Southern Pine Migrant Education Association P.O. Drawer 745
Nashville, Georgia 31639 912/686-2053

SP - 11

GA WIC PROCEDURES MANUAL FY '96

Attachment SP-3

TELAMON CORPORATION (Migrant and Seasonal Fannworker Association, Inc.)

Offices Valdosta Office 1012 Williams Street Valdosta, Ga. 31601 (912) 244-4920 (912) 244-4921 (FAX)
Lyons Office 143 East Liberty Avenue Lyons, Ga. 30436 (912) 5263094 (912) 526-6850 (FAX)
Dublin Office 112 East Johnson Street Dublin, Ga. 31021 (912) 275-0127 (912) 275-7548 (FAX)
Douglas Office 613 West BakerHwy. P.O. Box 966 Douglas, Ga. 31533 (912) 384-8856 (912) 384-8929 (FAX)
Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, Ga. 30358 (912) 764-6169 (912) 489-5616 (FAX)

Field Offices Supervisors Carmen Wilkinson Program Coordinator
Elmira Reynolds Employment and Training Specialist
Employment and Training Specialist
IlIIBII
Employment and Training Specialist
Elsie Trethaway Employment and Training Specialist

SP - 12

GA WIC PROCEDURES MANUAL FY '96
Moultrie Office 19 1st Street S.E. Mouhrie, Ga. 31776 (912) 985-7507 (912) 985-7305 (FAX)
Blackshear Office 3351 West Highway 84 P.O. Box 413 Blackshear, Ga. 31516 (912) 449-3016 (912) 449-4579 (FAX)

Attachment SP-3 cont'd Supervisors Beverly Scretchen Employment and Training Specialist
Deputy Director
!~~~:!~!~Training Specialist

1)

Ms. Raynita Smith

2)

Ms. Susan Johnson

KIDDLE KASTLE I

KIDDLE KASTLE II

684 N. Washington Street

III Oliver Lane

Lyons, Ga. 30445

Glennville, Ga. 30427

(912) 526-9558

(912) 654-2182

(912) 654-2190 (FAX)

SP - 13

GA WIC PROCEDURES MANUAL FY '96

Attachment SP-4

INTERPRETER SERVICES THROUGH GEORGIA REFUGEE HEALTH PROGRAM

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.

STATE REFUGEE PROGRAM OFFICE

.@!J~$~!l, Director
Laliberte-Carey, Health Services Specialist

(404) 657-2552 (404) 657-2563

COUNTY COORDINATORS

Dao Hongkham (Lao, Vietnamese) Senior Co=unity Epidemiologist Dekalb & Clayton Counties Dekalb County Health Department 440 Winn Way Room 137 Decatur, GA 30033 508-7785 .

r- ' Dung Krall (Vietnamese
Senior Co=unity Epidemiologist Fulton County Fulton County Health Department 99 Butler Street 4th Floor Atlanta, GA 30303 730-1567

Greater Atlanta

REFUGEE HEALTH INTERPRETERS

Chanthary Chea Camtu Van Duong Berhane Habte SiyaKim Margarita Tselesin

Cambodian, Vietnamese Vietnamese Amharic, Tigrigna, Russian Cambodian Russian

(404) 508-7785 (404) 508-7785 (404) 299-3215 (404) 657-2563 (404) 657-2641

Gainesville

Anita Gougelmann

Vietnamese

(404) 531-5600 GIST 261-5600

SP - 14

GA WIC PROCEDURES MANUAL FY '96

Attachment SP-5

GEORGIA INTERPRETER SERVICES FOR THE HEARING IMPAIRED

Robin Titterington, Director Brian Green, contact person Two Peachtree Street, N.E. Atlanta, GA 30303

(404) 894-8558 TTD (404) 894-5604 TTD 1-800-228-4992

SP - 15

I I I I I I I I I I I I I I I I I I I I I I I
I

TABLE OF CONTENTS

1. General ___________ _

..............

II. Methods of Outreach

_

III. Agencies to Contact for Outreach

IV. Public Notification. . . . . . . . . . . . . . . ..

_. __ _.. _
.

V. Outreach During a Waiting List. . . . . . . . . . . . . . . . . . . . . . . . .

.

VI. Program Costs. _ _

_. . . . . . . . . . . . . .

__

Page OR-l OR-2 OR-2 OR-3 OR-3 OR-3

Attachments:

OR-l WlC Outreach Card (Small)

_. . . . .

OR-2 WlC Outreach Card (Large)

_

_

OR-3 FlyerJPoster

_.. _. . . . . . . . . . . . . . . . .

OR-4 Georgia Wle Resource Referral Guide. . . .

.

OR-5 Georgia WlC Program Fact Sheet. _. _ _. . . . . . . . . . . . . . . .

OR-4

OR-5

.

OR-6

OR-7

.. _.. OR-8

I I I I I I
I I I I I I
I I I I I I
I I

GA WIC PROCEDURES MANUAL FY '96
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. Improve the health of pregnant women and children.
2. Increase public awareness of the benefits of the WIC Program.
3. Inform potentially eligible persons about the WIC Program in order to encourage and promote their participation in the program.
4. Inform health and social service agencies ofthe WIC Program's qualifidltions for participation and encourage referrals.
5. Ensure cooperation between WIC and other related services and programs so that WIC benefits and other related services a participant may be receiving are coordinated to provide more comprehensive service.
6. Promote a positive image of the WIC Program.
7. Generate additional information for the Hispanic population.
Each local agency should develop and implement an outreach/referral system and a plan to coordinate the WIC Program with other programs and services which serve potential WIC applicants. The outreach system, plan, and all activities conducted should be documented and kept on file for three (3) years plus the current year.
Outreach activities should also be aimed at other health and social service agencies which provide services to potential WIC applicants. Including such agencies in outreach activities will encourage those agencies to make referrals to WIC. Significant program changes (e.g. new income guidelines, new nutritional risk criteria, etc.) should also be shared with these agencies. Outreach information should also be made available to minority groups and grassroots organizations.
An effective outreach/referral system, and a plan for coordination of services, requires that a local agency be aware of what services are available in the community which may be of interest to or benefit WIC participants. Additionally, it requires a cooperative relationship between the local agency and these other services. For these reasons, the State agency strongly encourages Districts to conduct outreach activities at the clinic level as well as the district level.
OR-I

GA WIC PROCEDURES MANUAL FY '96
When funds are available, the State WIC Office 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 ofinformational posters, brochures, displays in public places, presentation at meetings and clubs, and advertisements through local newspapers, radio, or television. Ifa 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.
The State agency has developed the following outreach materials for local agency use:
I1. Outreach Cards (See Attachments OR-I and OR-2)
2. Flyer (that can also be used as a poster) (See Attachments OR,~3) Georgia WIC Resource Referral Guide (See Attachment OR-tf)
ID. AGENCIES TO CONTACT FOR OUTREACH
Examples of agencies, offices, and organizations which should be contacted regarding outreach, referral, and coordination of services include:
I. Alcohol!drug abuse counseling and treatment centers 2. Family Planning programs 3. Child abuse counseling centers 4. Physicians, NurseslNurse Practitioners 5. Health and medical organizations 6. Hospitals and clinics 7. Pharmacies 8. Welfare offices 9. Unemployment offices 10. Social Service agencies II. Religious and community organizations 12. Agencies offering services for homeless families and individuals 13. Housing Authority 14. High Schools and Counselors 15. Migrant Offices 16. Military Bases 17. Retail Stores (Kmart, Walmart, etc.) 18. Day Care Centers
OR-2

GA WIC PROCEDURES MANUAL FY '96
19. Charitable organizations (Goodwill, Salvation Army, etc.) 20. Headstart Programs IV. PUBLIC NOTIFICATION The State agency, through the Office ofPublic Information, will distribute at least annually, outreach information to every newspaper and radio station in Georgia. All outreach materials must include the WIC non-discrimination statement. V. OUTREACH DURING AWAITING LIST When local agencies reach their maximum caseload and a waiting list is instituted, outreach activities should be concentrated on the highest risk population. - : VI. PROGRAM COSTS Only costs of promotional efforts designed to encourage and increase participation in the WIC Program are allowable. Outreach efforts should be consistent with the health oriented nature of the WIC Program. Outreach expenditures are not allowable for meeting breastfeeding expenditure requirements.
OR-3

GA WIC PROCEDURES MANUAL FY '96
WIC OUTREACH CARD (small)
It you are cxpE:ding a baby_ or already have smaU chHdren.WlC can hdp you eat better. lhc Women, Infants and Children program gives food to Iow-income pregnant women, new mothers and smaU chHdren. Ask your county health department how to qualifyforWlC, or
can 1--l1OG-228-9173.

Attachment OR-I

Form #3752

Ifyou are going to Mve a baby, get healthy food, nutrition lnforrna1ion and a medical checkup right away. lhc county health department and WlC can
help. After the baby is born, stay healthy and give your baby healthy food. Breasttecding is best for most
babies WlC can help you get milk, cheese, eggs, juice, cereal, peanut butter, beans and baby formula.

llis is,," EQuoI Opportl.nity~ tf)OU beI~ 'rOO~
bc:cnc:Xscrirnin5led~bc::.euseofRICC.coIot".~ origin, so:.~or hldicap. Yo1ilt: inmedi4tdylOthe ~ot"~Weshingto\.D.C.202S0.

il

OR-4

GA WIC PROCEDURES MANUAL FY '96

Attachment OR-2

\ front)

WIC OUTREACH CARD (large)
(back)
WIe Foods include:
milk, cheese,eggs,juice, cereal, peanut butter, beans,
and infant fonnula.

WIC
Means FREE FOOD ..and Nutrition lnfonnation if you are:
*Low-income *Pregnant "*Have 1" or more children underage 5
You can be working and may still qualify!!!
TO FIND OUT MORE:
CALL YOUR LOCAL HEALTH DEPARTMENT OR CALL 1-800-228-9173

Be sure to ask about evening clinics for working families.
WIC._Iit-I~""'c- If:r-~"""a..w
",-~ ....... ~a-.Ol&al'.~ . . . . .a.. . .......,.'WriIc~yto*s.ec-.y ~ w.-..-.,o.c.2Cl:UQ.

Form #3765 (English) Form #3754 (Spanish)

OR-5

GA WIC PROCEDURES MANUAL FY '96

Attachment OR-3

FLYERIPOSTER

Expecting A Baby?

.

Already Have Small Children?

THEN HOP TO IT!

Get Free Food - Milk - Eggs Cheese
- Cereal- Dried Bellns - fruit Juices Peanut Butter -Infant Formula
& Health Checkups - Far You and
Your Baby From The WIC Program If you ore unemployed or work and have alaw income, you moy qualify.
Call Your LoooI Heallh Department or
1-800-228-9173

Form #3749 (English) Form #3733 (Spanish)

OR-6

GA WIC PROCEDURES MANUAL FY '96

Attachment OR-4

GEORGIA WIC RESOURCE REFERRAL GUIDE
cr/ie (jeorgia
'WIC
Program
~ferral
(juUe
WJC dtiMSupport ~Gry
:FooaSuunps 5f.:F'DC {WeIfan} .
9>ft.tficaU{
C!iiM:Hdtfi
~Start
JTttJtUUtizcuio11. 'E:{ultSio11.:Fami!:g Living Program
W leORKS ONDERS

Form #3297

OR-7

GA WIC PROCEDURES MANUAL FY '96

Attachment OR-5

GEORGIA WIe PROGRAM
WOMEN, INFANTS AND CHll.-DREN NUTRITION PROGRAM (WIC)
FACT SHEET
GEORGIA DEPARTMENT OF HUMAN RESOURCES
WIC IN GEORGIA
The Women, Infants and Children Nutrition program provides low income women and their children up to the age of 5 years with special supplemental foods, breastfeeding support and education, and nutritional counseling.
Federal funds totalling $106 million will be spent in Georgia communities during Federal Fiscal Year 1995; while approximately $27.7 million will be received from Mead Johnson Nutritionals as a result of the infant formula sole source rebate initiative.
WIC give pregnant women, new mothers and children vouchers for basic foods including milk, eggs, cereal, dried beans, peanut butter; fruit juice and (for those who do not breastfeed) infant formula.
WIC staff encourages women to breastfeed and counsel them about nutrition. They identify affordable, prenatal care and encurage them to apply for Medicaid, Food Stamps, AFDC, Immunization and other health and human service agencies.
* Georgia's WIC Program is the 8th largest in the nation and 2nd largest in the southeast.
* WIC reaches aboutsixty-eight (68%) of those women and children estimated to be eligible
in Georgia. "WIC Works Wonders," a special outreach effort to increase participation, began in February 1991.
* The Georgia WIC Program served 211,587 women, infants and children during November
1994, as compared to approximately 118,000 participants in the fall of 1989.
* Infant formula rebates generated $13.7 million during Federal Fiscal Year '94. This
allowed the program to serve thousands ofadditional clients.

OR-8

GA WIC PROCEDURES MANUAL FY '96

Attachment OR-5

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 health care for infants are 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 prenatal care early in their pregnancy and to seek preventive care, such as immunization, for children.

Every dollar spent on WIC saves up to three dollars in health care costs, according to a national study.

WHO IS ENTITLED TO RECEIVE WIC BENEFITS?

To qualifY for WIC benefits, a woman must have a total family income of no more than 185 percent ofthe federal poverty level. She must be either pregnant or breastfeeding, or have given birth within the past two months. Children are eligible up to their fifth birthday.

* The two highest program priorities are: enrolling women in their first trimester of
pregnancy; and encouraging women to breastfeed.

Working women who meet program eligibility requirements are also a target population.

* A woman or child on WIC must be at risk for impaired health due to nutritional deficiencies,
including, but not limited to: low birth weight, anemia, abnormal weight gain during
pregnancy, a history of high risk pregnancies, or inadequate diet.

Women wishing to apply for WIC may make inquiry at Grady Hospital and Southside Healthcare, Inc., in Atlanta as well as public health departments throughout the state.

OR-9

GA WIC PROCEDURES MANUAL FY '96

Attachment OR-5

* An income of 185 percent of the federal poverty level equals: (effective March 23, 1995 March 23, 1996)

Family Size
2 3 4 5 6 7 8
For each additional family member

Yearly $13,820 18,556 23,292 28,028 32,764 37,500 42,236 46,972
$ 4,736

Monthly $1,152 1,547 1,941 2,336 2,731 3,125 3,520 3,915
$ 395

Weekly $266 357 448 539 631 722 813 904
$ 92

OR-IO

GA WIC PROCEDURES MANUAL FY '96 WICLOGO

Attachment OR-6

Georgia VVIC Program
OR-II

,-

, -,

TABLE OF CONTENTS

Page

I. General ...

FD-l

II. Types ofWIC Vouchers

FD-2

A. Computer Printed Vouchers

FD-2

B. Blank Manual Vouchers

FD-2

C Preprinted Standard Manual Vouchers

FD-2

D. Automated Special Manual Vouchers

FD-3

III. Voucher Issuance - General

FD-3

A. Valid Certification Period ...

FD-3

B. Identi~cation of Person Picking Up Vouchers

FD-3

C Corrections ....

FD-3

D. Bi - Monthly Issuance

.

E. Categorically Ineligible

. . . . . . . . . . . . . . . . FD-4

F. Issuance of Vouchers to Family Members. .

. . . . . . . . . . . . . . . . FD-4

IV. Computer Printed Vouchers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. FD-Il:

A. Data Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Voucher Cycles

FD-i FD-~

C. Voucher Packaging . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . .. FD-6

D. Voucher Shipments. . . . . . . . . . . .. . . . . . . . . .

FDJ12

E. Receipt of Vouchers . . . . . . . . . . . . . . . . . .

.

FD~!g

F. Inventory Control

: FDJ!~

G. Issuance of Computer Printed Vouchers

.

FDJll

v. Manual Vouchers

.

A. Blank Manual Vouchers

.

FDJ!~~

B. Preprinted Manual Vouchers or Special Manual Vouchers

FD-'):~

C. Ordering Manual Vouchers

.................... FD-l~

D. Receipt of Manual Vouchers

.................... FD~~@

E. Inventory Control of Manual Vouchers

FD-f~

F. Issuance of Manual Vouchers

. ................... _.,. FDil

G. Distribution of Manual Voucher Copies

FD--li

VI. Georgia WIC Program Identification (ID) Card

FD~I

A. General

.

B. Required Data

.

C. Participant Instructions ..

VII. Proxies . . . . . . . . . . . . . . .

.

A. General............

B. Reasons for Proxies

C. Authorization

................ FD~~~

.

FD~~g

.

FD~i~

FD-i~

.

FD-~g

FD-~~

FD-i~

D. Voucher Pick Up, Issuance, and Use

FD-@J

E. Restrictions F. Participant Instructions

FD-@j FD~~

VIII. Mailing WIC VoucherslDelivery ofWIC Vouchers

_ _ !Il~il[I!f.&ij

illi~

Ilmi~;lgll#.t wl!.1..I.I:I~iii~

lil~~l.\I"'I!i~II'.I.~ji:f.j!i.

FD-I

IX Voided Vouchers

.

A. 1~\jj,I;Computer Vouchers

B. iii4)IManual Vouchers

X Transporting Vouchers

XI. Prorated Vouchers

XII. Late Pick-Up of Vouchers

XIII. Security ofIssuance Materials

A. WIC Vouchers ....

B. WIC Program Stamps ...

C. VOC Cards

.

.. FD-gZ
. . . FD-gZ
...". FD~g~ ..... FD-g~
. '" FD-29
.. FD-$Q

....... FD~~l

.

FD~~l

.

FD~~[

XIV.
xv.
XVI. XVII. XVIII.

Redemption ofWIC Vouchers

. ... FD~ig

A. General ..

.... FD~ig

B. Checkout

.

FD~ig

C. Cashier Validation

.

.......................... FD~i~

D. Voucher Signatures

.

.

FD~~~

Replacement of Vouchers

.

.

FD~~~

A. Lost, Stolen, or Destroyed Vouchers

FD~~~.

B. Change ofFormula Order

FD~~

Automated Special Manual Voucher System

FD-~,~

Automated Special Manual Voucher System Equipment

FD~{i

Establishing Clinics/Clinic Changes

FD~~

Attachments:

FD-l Computer Printed Voucher

-. FD-42

FD-2 Blank Manual Voucher. . . . . . .

. FD-43

FD-3 Preprinted Standard Manual Voucher ..

. . FD-44

FD-4 Automated Special Manual Voucher. .

. FD-45

FD-5 Voucher Create Calendar

. FD-46

FD-6 Voucher Cycle Packing List. . . . . . . . .

.

FD-47

FD-7 Computer Printed Voucher Register ..

.

FD-48

FD-8 Voucher Register Summary Page

.

FD-49

FD-9 Transmittal Form. . . . . . . . . . . . . .

FD-50

FD-IO Form and Manual Voucher Orders

FD-5l

FD-ll Manual Voucher Inventory . . . . . . . . . . . . . . . . .

.

FD-52

FD-12 Batch Control Form. . . . . . . . . . . . . .

.

FD-53

FD-13 Batch Control Exception Report. . . . .

.

FD-54

FD-14 Georgia WIC Program Identification Card

FD-55

FD-15 Request to Establish New Clinic/Clinic Changes

FD-56

555555555! FD-16 DailyRosterlMonthly Mailed Voucher Report

FD-57

..~~I!~.;.If~.l~l,.l(;l.._.~r~I!;:_Bir~1:mi:i;tr!il1l:.

GA WIC PROCEDURES MANUAL FY '96

I. GENERAL

The Georgia WIC Program uses a uniform retail food delivery system. Participants are issued food instruments (vouchers) which are redeemed at authorized vendors for WIC foods. Clinics issue vouchers to participants, or their proxy, on a montWy or bi-]llontWy basis. Georgia has a fully automated food delivery and management information system. The State agency contracts with a data processing firm, the ADP Contractor, to establish and operate the system.

Persons requesting WIC benefits are screened for Program eligibility and are certified if

the applicant qualifies. Turnaround documents (TADs) containing demographic,

financial, medicaJJnutritional, and food package information are forwarded directly to the

Contractor in order to establish a participant masterfile. Several local agencies have the

capability of electronically transmitting information contained on the TAD via Computer

1~;:~)liBiWfii.i_~iJ~:~:I:~~~~~ ~~~~;:~e~~~~o;~~;:

.!B4E. vouchers and prepare' automated turnaround documents. Both.,ili~..Y,m!fhers and

turnaround documents (TADs) are submitted to the ADP contractors

These

local agencies only receive computer generated TADs under the following conditions:

Automated Termination Action, Automatic Update ofInfant to Child, and Transfers IN

or OUT of clinic.

Computer generated vouchers for each participants are printed by the ADP Contractor and sent to the appropriate clinic or districtllocal agency according to the participants pickup and interval codes. The Contractor also provides preprinted manual vouchers and special vouchers which can be issued to new and transferring participants.

Participants redeem the vouchers for specified kinds and quantities of foods at authorized vendors. Vendors deposit the redeemed vouchers in their local bank: accounts and the vouchers proceed through the banking system to a central clearing bank:. It is this clearing bank where the vouchers are edited for missing or invalid information. Vouchers which are not paid are sent back to the appropriate local bank and the vendor's account is reduced by the value ofthe vouchers. Vouchers paid, but flagged as suspect, are investigated by the State agency.

The State agency is responsible for any necessary recoupment of funds. The ADP Contractor reconciles individually issued and redeemed vouchers as required by federal regulations and maintains a voucher masterfile which tracks the status of all vouchers. The ADP Contractor also produces participation, financial, vendor, and' other management reports at regular intervals for use by State and local agencies.

FD-I

GA WIC PROCEDURES MANUAL FY '96
II. TYPES OF WIC VOUCHERS
There are four (4) types ofWIC vouchers which may be issued to participants:
A. Computer Printed Vouchers
These vouchers contain a specific food package, individually tailored for each participant's nutritional needs. Computer printed vouchers (Attachment FD-l) are produced by the ADP Contractor and contain information based on the TAD submitted by the clinic. District/clinic identification numbers are also printed on the vouchers.
B. Blank Manual Vouchers
These vouchers may be completed for new or transferring participants;to replace voided computer printed vouchers; to adjust a food package in the event oflate pick up by a participant; or to supplement the preprinted manual voucher food package. All information pertaining to the participant, as well as the food package prescribed, must be completed by clinic staff at the time of issuance. (See FD-V.F. for procedures.) The clinic information is preprinted on blank manual vouchers (Attachment FD-2).
C. Preprinted Standard Manual Vouchers
Standard manual vouchers are unburst sets offour (4) food package types. These vouchers contain a preprinted standard food package (Attachment FD-3). Standard voucher sets should not be broken to issue single standard vouchers. The four (4) types offood packages available are: 1. Infants (Food Package l:i~). These preprinted manual vouchers provide
formula only.
2. Pregnant and Breastfeeding Women (Food Package 404). These preprinted manual vouchers provide a moderate food package for pregnant and breastfeeding women.
3. Postpartum Non-Breastfeeding Women (Food Package 502). These preprinted manual vouchers provide a moderate food package for postpartum, non-breastfeeding women.
4. Children (Food Package 603). These preprinted manual vouchers provide a moderate food package for children.
FD-2

GA WIC PROCEDURES MANUAL FY '96
D. Automated Special Manual Voucher - See FD-XVII
Automated Special Manual Voucher are similar to Preprinted Standard Manual Vouchers except the food messages are blank. Automated clinics use these forms to prepare manual vouchers for any food package. (see Attachment FD-4).
Ill. VOUCHER ISSUANCE-GENERAL
A. Valid Certification Period
Do not issue vouchers to any participant who is overdue for certification.
B. Identification of Person Picking Up Vouchers
Before issuing vouchers, the clinic staffmust check the WIC ill card for signatures ofparticipantlproxy. Ifa proxy is picking up the vouchers, his/her signature must be on the ill card. If a participant has not previously had a proxy sign their ill card, the proxy must have a dated note, ,signed by the participantlparentlguardian/caretaker, giving him/her the. authority to pick up vouchers for the participant. The proxy/authorized representative must also pres~t some form ofidentification to verifY that he/she is the person authorized by the participant to pick up vouchers. Ifa participantlparentlguardian/caretaker does not possess, or has lost his/her ill card, other identification may be accepted as verification and a new ill card issued. A proxy must be at least 16 years old.
C. Corrections
Vouchers may not be corrected or altered in any way unless prior authorization is received from the State WIC Office. If an error is made during issuance, the voucher(s) must be voided (See FD-XI.A., "VoidedVouchers"). Correction fluid ("white-out") may not be used on vouchers for any reason.
D. Bi-Monthly Issuance
Local agencies have the option to issue vouchers to participants bi-monthly. If a local agency chooses to convert an entire clinic or all clinics within a district to bimonthly issue, prior approval from the State WIC office must be obtained. With bi-monthly issue, clinic staff must explain to participants that the second set of vouchers may not be used before the "First Day to Use" on the vouchers. For computer printed vouchers, the actual date of receipt will be noted on the voucher register.
FD-3

GA WIC PROCEDURES MANUAL FY '96
E_ Categorically Ineligible
Categorically ineligible refers to the period of time a client is no longer eligible to receive WIC benefits because of selected categories. Participants who are subject to be categorically ineligible are postpartum women, infants and children who reach their 5th birthdates and breastfeeding women who stop breastfeeding and are greater than six (6) months postpartum. However, at any point and time-during a federal fiscal year, and dependent upon availability funds, higher priorities may be subject to being categorically ineligible. The categorically ineligible message will appear on the voucher register for the last set of vouchers prior to the termination date (for more information, see 102 in the User's Manual).
When a participant becomes categorically ineligible before the end of the month, eligibility is extended to the end ofthe month. In case of suspected fraud or abuse, immediate termination is in order.
A full set ofvouchers must be issued when a client becomes categorically ineligible before the end ofthe month (i.e_ child becomes 5 years of age or a woman is six (6) months postpartum or a breastfeeding WOman stops breastfeeding and is greater than six months postpartum). The issuance of a full set ofvouchers provides the client with quality health care benefits for a few more days/weeks while at the same time conveys a "human"/people oriented side to a program heavily laden with administrative work.
F. Issuance of Vouchers to Family Members
Vouchers must never be issued by an employee to a Family Member or other related blood person; nor other person residing in the same household. Failure to comply with these procedures will result in payments of food cost to the State WIC Office and may result in administrative disciplinary action by the local agency.
IV. COMPUTER PRINTED VOUCHERS
A Data Elements
The following data elements appear on the face of the computer printed vouchers:
I. District/Unit/Clinic. The district is represented by a two-digit number, the unit by a one-digit number, and the clinic by a three-digit number.
2. WIC ill Number. The participant's unique identification number which corresponds to the number on the TAD.
Self-Check Digit. Calculated by the ADP Contractor.
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GA WIC PROCEDURES MANUAL FY '96
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).
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.
6. Vendor Must Deposit by (MMDDYY). The date by which the vendor must deposit the voucher. Vouchers not deposited by this date are considered stale dated and will not be paid by the Contract Banle
7. Voucher Number. A unique serial number printed on each voucher.
8. For These Items/Quantity Only. A preprinted description of the food items and the quantities to be purchased. Also, the food package and voucher codes are printed here.
9. WIC Program Stamp. Pre-printed Georgia WIC Program Stamp.
10. Maximum Purchase Price. The actual purchase price may not exceed this amount.
II. Pay Exactly. This space is left blank for the vendor to enter the actual amount ofthe WIC foods purchased.
12. WIC Vendor Stamp. Stamped by the vendor prior to deposit.
13. Sign Here At Grocecr Store. The participant/proxy signs his/her name in this space when the voucher is redeemed at a WIC vendor.
The reverse side of the computer printed vouchers contains an area for endorsement by the authorized WIC vendor.
B. Voucher Cycles
The voucher pickup day is determined by the clinic staff and participant. This day is entered as a Pickup Code on the TAD.
Whether or not computer printed vouchers will be printed for the participant during
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GA WIC PROCEDURES MANUAL FY '96

the next printing of the selected voucher cycle is dependent upon the time of submission ofthe TAD to the ADP Contractor and the scheduled printing for that voucher cycle.

Based on the cutoff dates of the 15th and the last day of each month, the ADP Contractor produces the computer printed vouchers and related report~ twice a month. The first cycle ofvouchers (cycle I) consists of those with issue dates from the first through the fourteenth of the month (Pickup Codes IA through 2E) and the second cycle (cycle 2) consists of those with issue dates from the fifteenth to the twenty eighth (28th) day of the month (pickup Codes 3A through 4E).

Whether one (1) or two (2) months of vouchers are produced depends on the

Interval Code entered on the TAD (1 = monthly; 2 = bimonthly, even; 3 =

bimonthly, odd). Please refer to the "Voucher Create Calendar", for a one (1) year

calendar of voucher issuance (Attachment FD-5).

-,

C. Voucher Packaging

In each clinic package the vouchers are in alphabetical order based on the last name of the lead family member within each Site Code. The lead family member is the one with WIC Type P, N, or B or the one with the lowest Participant ill Number (usually #1).

1. The following items will be included in each clinic package (or clinic package #1 ifthere is more than one [l]):

a. Voucher Cycle Packing List (Attachment FD-6)

This (2-ply) packing list provides the specific beginning and ending voucher numbers for all the computer printed vouchers (and for the manual vouchers when appropriate) for the clinic. It also lists the appropriate pages of the Computer Voucher Register that accompany the clinic's computer printed vouchers. Two copies ofthe packing list are provided in order that the clinic may retain one copy and send one signed copy to the district/unit as acknowledgement of receipt of the vouchers.

b. Computer Printed Voucher Register (Attachment FD-7)

Purpose - To provide a listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers. The register is organized in the same order as the computer generated vouchers.

FD-6

GA WIC PROCEDURES MANUAL FY '96

Distribution -

Clinic DistrictJUnit State

I copy I copy, Summary I microfiche copy

Frequency - twice each month, with each voucher cycle

Sequence - DistrictlUnit, clinic, Site Code, alphabetic by name oflead family member.

Register Description -

Line I

WIC ill: The WIC ID number of each participant.

PARTICIPANT NAME: The name ofthe woman participant or the participant in the family having the lowest Participant ID Number. The register is in sequence by this name, then all other family members, regardless oftheir last name, fall in sequence by WIC ID/Participant Number.

MI: Middle Initial

MEDICAID REFERRAL: Code to indicate Medicaid Program participation or income as a percent of the Federal Poverty Guidelines. The numbers indicate the level of poverty and are as follows:

M: If the client is enrolled in Medicaid.

0-1 2 3 4 5

0-100% 101-125% 126-150% 151-175% 176-185%

Poverty Poverty Poverty Poverty Poverty

TYPE: WIC type P, N, B, I, C

PR: Priority

SIGNATURE OF PARTICIPANT: Space for participant! proxy signature.

DATE: Space for the date vouchers are picked up. The date

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GA WIC PROCEDURES MANUAL FY '96
must be filled in by the participant/guardian! caretaker/proxy or the issuing authority. NOTE: The issue date appears under this line.
CLK INIT: The staff person must initial here when vouchers are issued, voided, or subsequently detenmned to be ullclaimed.
Line 2
TELEPHONE NUMBER: Phone number ofparticipant.
VOUCHER NUMBERS: The voucher numbers are listed across the four (4) columns below the Name. NOTE: If the participant has an interval code of 2 or 3, a second line of infonnation is printed for the second set ofvouchers. ~
TOTAL: The number ofvouchers produced for the participant.
MESSAGE: Applicable messages regarding participant's need for subsequent certification, no show, automatic changes, etc. The following is a complete list of messages. The due date follows the message.
NUTRITIONAL ASSESSMENT - MMDDYY For infants who are certified prior to six (6) months of age, the infant's six (6) month anniversary is printed.
RECERT DUE - MMDDYY Subsequent certification is due in the same month as or the month after the voucher issue month. For breastfeeding women and children, the date is the certification date plus six (6) months.
RECERT DUE (P) - MMDDYY Subsequent certification is due in the same month as or in the month after the voucher issue month. For pregnant women, the date is the forty
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GA WIC PROCEDURES MANUAL FY '9.6
five (45) days from the EDe.
RECERT OVDUE - MMDDYY For breastfeeding women and children, subsequent certification is overdue based on the certification date plus six (6) months.
RECERT OVDUE (P) - MMDDYY For pregnant women, subsequent certification is overdue based on the EDC plus fortyfive (45) days.
1ST BDATE - MMDDYY Infant's birthdate is in the month after voucher issue month. Date printed is birthdate.
CATEG TERM - MMDDYY Participant is categorically ineligible in month after voucher issuance month. Message accompanies last set of vouchers. Date printed is categorical termination date.
FOR N - Delivery Date plus 6 months
FOR B - Delivery Date plus 12 months
FOR C - At 5th birthday
ISSUE DATE: The date of issue printed on vouchers.
2. The DistrictlUnit receives the following items with each voucher shipment:
a. Voucher Cycle Packing List (Attachment FD-6)
Two copies of the clinic packing list are sent to the clinic with the vouchers. Another copy of the clinic packing list is sent to the local agency/district to be used by the DistrictlUnit to ensure that each clinic
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GA WIC PROCEDURES MANUAL FY '96
reports acknowledgement of the Voucher Package. The local agency/district also receives a summary of all vouchers issued to that district/local agency.
b. Voucher Register Summary Page (Attachment FD-8)
This summary page includes:
(1) Total participants who receive computer generated vouchers.
(2) Total vouchers for the DistrictlUnit.
(3) Total number of messages by message type.
i i i l (4) Signature line and register
D. Voucher Shipments
Vouchers may be shipped to the local agency/district office or directly to each clinic. Vouchers sent to the district office are packaged by clinic. Vouchers are shipped by Federal Express and are received by local agencies on the 22nd day of the month for the next month's cycle I and on the 7th day ofthe month for cycle 2 of the same month. For clinics who receive direct shipments from the ADP Contractor and State WIC Office, the expected arrival date is no later than three (3) days prior to the "first day to use".
E. Receipt of Vouchers
Upon receipt of the packages of computer printed vouchers, the responsible personnel (local agency/district or clinic) must review the packages and count the contents. To insure that all items have been received, the voucher numbers must be checked and verified with the Voucher Cycle Packing List (Attachment FD-6). Any discrepancies must be reported to the ADP Contractor immediately. The packing list must be signed anddated to verify receipt. A copy ofthe signed/dated packing list must be mailed to the local agency/district office within two (2) days of receipt of the vouchers.
The original must be retained by the clinic for three (3) years plus the current Federal Fiscal Year. The local agency/district must mail all signed/dated packing lists to the ADP Contractor by the 1st or 15th of each month.
If a shipment is not received by the expected arrival date or the shipment is
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GA WIC PROCEDURES MANUAL FY '96

incomplete, notifY the ADP Contractor and the State WIC Office. All rerun requests must receive prior approval from the State WIC Office.

F. Inventory Control

The ADP Contractor conducts a one-hundred percent (100%) verific;ation of computer printed vouchers to insure that each voucher is correct and that the vouchers packed in each clinic package are correctly reflected on the packing list.

G. Issuance of Computer Printed Vouchers

It is recommended that vouchers not be issued significantly in advance of the "First

Day to Use" to avoid confusion. Vouchers must never be issued more than six

(6) days in advance ofthe "first

se" date.

x

iii.i~iiifrthIY issuance..

A participant may have from one (1) to eight (8) computer generated vouchers issued depending on the Food Package and the Interval Codes. The following procedures must be followed when issuing computer printed vouchers:
1. Identification. VerifY the identity of the person picking up vouchers. Please refer to page FD-ill.B., "Identification of Person Picking Up Vouchers", for procedures.
2. Computer Printed Voucher Register. The computer printed voucher register lists all vouchers, in sets, for a participant sequentially on a single line, rather than each voucher on a separate line.
Please refer to page FD-IV.B. for an explanation of the messages. These
must be used as controls to "prevent unauthorized voucher issuance to a
participant.
The serial numbers of computer printed vouchers are preprinted on the voucher register. These numbers must match the serial numbers of the vouchers being issued. Clinics may not alter the serial numbers listed on the register.
The name of the participant on the voucher will be compared to the participant's name on the voucher register and on the WIC ill card. The names must be identical.
The following items must be completed on the computer voucher register each time vouchers are issued:

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GA WIC PROCEDURES MANUAL FY '96

a. Signature of Participant or Proxy. The participant or proxy must sign his/her name here to indicate that those specific vouchers have been received by the proper person. Tbis signature must match the signature of the participant or proxy on the ill card. The signature must be secured next to each set of vouchers received OR the recipient must sign next to the first set of vouchers received and enter bis/h~r initials next to all subsequent sets of vouchers received.

(1) Vouchers must not be issued until after the participant/proxy signs the register and the stafT person enters hislher initials.

(2) If a participant or proxy leaves the clinic without signing the register, the issuance must be documented by clinic staff. The issuing staff person must write "failed to sign" ana initial the appropriate line(s). "Failed to sign" may not be abbreviated.

. (3)

During a monitoring review, if one (1) percent or more of "fail to sign" appears on the Voucher Register 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 Voucher Register.

NOTE: Clinic staff will be held accountable for all "fail to sign."

(4) If the participant or proxy is unable to write, he/she will enter his/her mark in lieu of a signature. Clinic staffwill print the person's name next to the mark and initial the mark to indicate that it has been witnessed.

b. Date Issued. Enter the actual date the participant or proxy received the

vouchers. Ifthe same date needs to be entered on consecutive lines, it

can be entered next to the first signature and a line may be drawn OR

..

nt lines.

c. Clerk Initial. The staff person must initial here when vouchers are issued, voided. When issuing vouchers, the stafT person must initial after the participant/proxy signs, but before vouchers are issued.
3. Voucher ParticipantJProxy Signature. The participant or proxy must sign each voucher in the left signature space, in the presence of the issuing staff person. Refer above to "Signature of Participant or Proxy", for instructions
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GA WIC PROCEDURES MANUAL FY '96
regarding the signature of participants who are unable to write.
4. Food Package Change. Food items on computer printed vouchers may not be crossed out in order to reduce the participant's food package unless prior authorization is received from the State WIC Office. Computer printed voucher(s) must be voided and replaced with manually issued vouchers ifthe food package is changed.
5. Transfer ofVouchers Within a Local Agency. Ifvouchers are sent/delivered to another clinic/service site within a Local Agency, a transmittal form must be used. The transmittal form is used for the purpose of documenting voucher pick-up and disposition of vouchers. The transmittal form is designed for use within a Local Agency clinic service area. For instance, a WIC client may be receiving other services in another area of the Local Agency, and the voucher register cannot be removed from the clinic, neither is it feasible for the client to come to the WIC clinic, a transmittal f.()rm may be used. The transmittal form aids the WIC staff in their efforts to issue vouchers without hardship to WIC clients. The use of the transmittal form by a Local Agency requires prior approval from the State WIC Office.
The following procedu,re must be followed:
a. A copy ofthe appropriate page(s) ofthe voucher register or transmittal form (see Attachment FD-9) must accompany the vouchers.
All other forms of documentation (i.e. void) utilizing the transmittal form must be followed in accordance with the computer printed voucher register procedures. Please refer to FDIV. G for instructions.
b. When thEl vouchers are issued, the participant or proxy must sign the copy of the voucher register or the transmittal form.
The transmittal form must include the client's name, clinic, voucher number(s), participant/proxy signature!date and the initials!date of the staff issuing the voucher(s).
c. The signed page(s) of this copy of the register or transmittal form will be returned to the original clinic and attached to the original voucher register.
d. An individual site code should be assigned when participants are in a specified geographical or otherwise related area (i.e. common site of employment or established "satellite clinic. ")
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GA WIC PROCEDURES MANUAL FY '96
6. Damaged Voucher. If a computer printed voucher is damaged during issuance and is voided, a blank manual will be issued by clinic staff
7. MailinglDelivery ofWIC Vouchers (See FD-26)
V. MANUAL VOUCHERS
Manual vouchers are very similar to computer printed vouchers. The primary differences are:
1. Manual vouchers are three (3) part forms. The parts are color-coded for distribution as follows:
First copy (blue) - participant Second copy (red) - ADP Contractor Third copy (black) - clinic
2. All manual vouchers require completion ofparticipant and issue data.
3. Blank manual vouchers require an additional entry offood quantities.
4. Automated Special Manual Voucher for on-site manual voucher printing. (Refer to FD-XVII.A for more information on these vouchers.)
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 for newly certified, reinstated, or transferring participants until computer printed vouchers are available.
2. To provide vouchers for a food package other than that provided by the
computer printed vouchers. Ifa permanent food package change is required, the TAD must be updated and submitted to the ADP
Contractor for correct computer printed vouchers to be issued in the future.
3. To provide WIC approved foods for prescribed packages that are not routine and do not have a computer food package number.
4. To provide vouchers to a participant who is late for pickup and has either had their vouchers voided or requires a prorated food package.
5. To replace one or more computer generated vouchers that have been lost, stolen, or destroyed. (See X. in the QI Section)
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GA WIC PROCEDURES MANUAL FY '96

6. To replace one or more damaged computer generated vouchers.

B. Preprinted Manual Vouchers or Special Manual Vouchers

Preprinted manual vouchers are issued for the following reasons:

1. To issue vouchers to newly certified, reinstated, or transferring participants until computer printed vouchers are available.

2. To substitute for a set of computer printed vouchers which were never received from the ADP Contractor.

3. To replace computer printed vouchers that have been lost, stolen, damaged, or destroyed (see X in the QI Section)

4. To issue partial sets for prior month after computer vouchers have been returned to the ADP Contractor as unclaimed.

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"

(Attachment

FD-lO) and must be received by the ADP Contractor by

25th of each

month. The ADP Contractor will fill manual voucher orders ship them with IIkcle r~computerprinted vouchers. .

a month and will

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 State WIC Office 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 three (3) years plus the current Federal Fiscal Year. The district/local agency must mail all signed/dated packing lists to the ADP Contractor by the 1st or 15th of each month.

2. DistrictlUnit

The DistrictlUnit receives a copy of each detailed clinic packing list for

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GA WIC PROCEDURES MANUAL FY '96
control, and a summary copy showing total vouchers received from the DistrictlUnit. Any discrepancies must be reported to the ADP Contractor immediately. Missing shipments must also be reported to the State WIC Office.
E. Inventory Control ofManual Vouchers
When manual vouchers are received, the serial numbers must be recorded in the "Received" column of the "Manual Voucher Inventory" log (Attachment FD-II). This documentation must be completed the same day the vouchers are received by a responsible WIC person.
1. Perpetual Inventory
The perpetual inventory accounts for the number of vouchers issUed, voided, and on hand. It is strongly recommended that this inventory be kept daily, but it must be kept weekly, at a minimum. The perpetual inventory shall be documented on the "Manual Voucher Inventory" log. All columns ofthe log must be completed accurately and legibly.
2.' Physical Inventory
All manual vouchers must be physically counted. A physical inventory of manual vouchers must be conducted weekly by at least one person and verified monthly by a second person. Both staff members must initial and date 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."
When discrepancies are discovered during a manual voucher inventory, they must be reported to the District WIC Coordinator immediately. Manual Voucher Inventory logs must be retained for three (3) years plus the current Federal Fiscal Year.
F. Issuance of Manual Vouchers
Within an issuance site, manual vouchers will be issued in complete sets, in consecutive order. When preparing manual vouchers, all items will be printed clearly and legibly, using a ball point pen. If an error is made on a voucher, void the voucher and issue a blank manual voucher.
Under normal circumstances, manual vouchers for new or transferring participants are issued for a thirty (30) day period. Bi-monthly issuance clinics may also issue
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GA WIC PROCEDURES MANUAL FY '96
a second set ofvouchers. The date on all vouchers must be the date on which the vouchers are issued (except bi-monthly issuance). The pickup code normally assigned is approximately the same day as the day on which vouchers are issued.
For example: Sally R is certified on January 18, 1990. She is assigned a pickup code of3D. She receives four (4) preprinted manual vouchers (Food Package 603), all dated January 18, 1990. Sally should return February 15, 1990 to pick up computer printed vouchers.
Bi-monthly issuance clinics may also issue a second set of vouchers. The dates on the first set of vouchers must be the date on which the vouchers are issued. The dates on the second set of vouchers must correspond to the pick-up code of the first set of vouchers.
In certain circumstances, when the TAD input cutoff date to the ADP Contractor cannot be met, enough vouchers should be issued to carry the participant until the next pickup date. Preprinted manual vouchers may be combined with blank manual vouchers in order to issue the correct number of vouchers until the next pick up date.
For example: Ms. Jones is certified on November 28, 1989. She is assigned a pickup code of lD. She receives four (4) preprinted manual vouchers (Food Package 404) all dated November 28, 1989. One (1) blank manual voucher is issued dated December 28, 1989. Ms. Jones should retum on January 4, 1990 to pick up computer printed vouchers.
The following procedure must be followed when issuing manual vouchers:
Identification
1. Verify the identity of the person picking up vouchers. See page FD-III.B., "Identification of Person Picking Up Vouchers" for procedures.
2. The following information must be added to the preprinted manual voucher at the time ofissuance:
a. Participant WIC ID number, including self check and participant code.
b. Participant's name (last, first). c. First day to use (MMDDYY).
d. Last day to use (MMDDYY) which is thirty (30) days from the "First
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GA WIC PROCEDURES MANUAL FY '96
Day to Use."
e. Vendor must deposit by (MMDDYY) which is sixty (60) days from the "First Day to Use."
f Food Package Code and Voucher Code. Ifblank manual vouchers are issued to replace damaged computer printed vouchers, the Food Package Code and Voucher Code from the computer 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.
3. The participant or proxy must sign each voucher in the left signature space, in the presence of the issuing staff person. Refer to FD-IV.G.2.a.(3), "Signature of Participant or Proxy", for instructions regarding the signature of participants who are unable to write.
4. Give the top copy (blue) to the participant.
5. When manual'vouchers are issued to a new participant during the initial certification appointment, the participant must receive an explanation on the proper procedure for redeeming vouchers. Whenever possible, the participant's proxy should be present during this explanation. The following is a guide to the information the participant/proxy should receive regarding the vouchers:
a. Sign on the left hand side of the voucher in clinic; countersign on the right hand side of the voucher in the grocery store.
b. Explain "First Day to Use" and "Last Day to Use."
c. Ifvouchers are lost, stolen, or destroyed, call the issuing clinic as soon as possible.
d. Never make changes on the voucher.
e. Explain what each voucher is good for, i.e. go through the foods and amounts.
f Explain the WIC approved foods. Point out the approved food list on
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GA WIC PROCEDURES MANUAL FY '96
the WIC Identification (ID) Card and encourage them to refer to this list when shopping. For those participants unable to read, visual aids should be used (i.e., posters, pictures, food displays). Explain that they are responsible for buying only WIC approved foods with their vouchers and they cannot substitute foods that are not WIC approved. To do so is considered Program abuse and could jeopardize their participation.
g. Encourage women and children to redeem one (I) voucher per week.
6. New participants should also receive an explanation of:
a. how the voucher pick up system works in their clinic.
b. when their pick up day is (i.e., 2nd Tuesday, 4th Thursoay, etc.), if applicable in their clinic.
c. how often they come to clinic to pick up (i.e., every month or once every two [2] months).
d. the late pick up policy.
e. what to do ifthey miss their pick up appointment.
f how to redeem vouchers at the grocery store.
G. Distribution of Manual Voucher Copies (Only when Handwriting Vouchers)
1. The second copy (red) must be accumulated, counted and mailed to the ADP Contractor using a Batch Control Form (Attachment FD-12). Whenever possible, do not separate or fold the second copies. DO NOT BATCH VOUCHER COPIES WITH TADs. They may be sent together to the ADP Contractor, but must be batched separately. When sending via Express Mail, do not use a Post Office Box.
For clinics with Automated Manual Voucher Systems, the second copy (red) may be filed with the third copy (black) since the diskette provides the issue information to the ADP Contractor.
2. The third copy (black) 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 sign or stamp a copy of the Batch Control Form to acknowledge receipt and return
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GA WIC PROCEDURES MANUAL FY '96
it to the clinic on a monthly basis (with a TAD shipment). If there are discrepancies, the ADP Contractor will send the clinic a form referred to as "Batch Control Exception Report," describing the discrepancy (Attachment FD-13). Discrepancies should be resolved by recounting vouchers, and contacting the ADP Contractor to resolve count differences by WIC ill if necessary.
When the signed Batch Control Form is returned to the clinic, the clinic voucher copies may be separated from the Batch Control Form and filed appropriately. 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 line binders, post binders, or expanding file folders in order to maintain them neatly.
Voucher copies must be retained for three (3) years plus the current Federal Fiscal Year. Signed/stamped Batch Control Forms and forms describing discrepancies can be destroyed after reconciliation is complete.
VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD
A. General
A Georgia WIC Program Identification (ill) card (Attachment FD-14) must be completed and issued, during the certification appointment, to any person who is enrolled in the Program. An ill card must never be issued to a proxy at initial certification. In instances where more than one (1) family member has been certified, each name should be listed on the ill card rather than issuing each family member a separate card. The ID card may be used for two (2) certification periods. Clinic staff must be certain that the person is properly certified for the Program before issuing an ill card.
At each voucher pickup the ill card or another form ofvalid identification must be checked before vouchers are issued. The ill card or another form of valid identification must be presented by the participant, parent, guardian, caretaker, or proxy each time vouchers are picked up at the clinic. If a participant/parent/guardianlcaretaker does not possess, or has lost hislher ill card, other identification may be acceptable as verification and a new ill card issued. (Valid examples are: Social Security Card, Birth Certificate, Driver License, etc.).
B. Required Data
Items on the front must be fully completed before issuing the ill card.
FRONT:
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GA WIC PROCEDURES MANUAL FY '96

1. Participant's name 2. WIC ill number 3. Date certification period expires 4. Participant/parent!guardian!caretaker's signature 5. EDC date 6. Signature ofproxy(s), ifthe participant designates one*A,B 7. Signature of clinic WIC official 8. Date card was issued 9. The WIC Program stamp must be stamped in the designated box

A

Refer to page FD-12 ifthe participant/parent/guardian!

caretaker~ or proxy is unable to write

B. This may be accomplished by the participantlparent/ guardian! caretaker after he/she has left the clinic.

It is recommended that all of the information on the back of the ill card be completed.

BACK:

1. Appointment information 2. Voucher pickup code 3. Voucher interval code 4. Comments 5. Clinic identifYing information

C. Participant Instructions

Participants/parents/guardians/caretakers must receive an explanation on the instructions on the purpose and use ofthe ill card. The following is a guide to the information that should be given to the participant regarding the WIC ill Card. Whenever possible, the participant's proxy(s) should be present during the explanation.

1. The ill card is to identifY you as an authorized WIC participant when picking up and/or redeeming vouchers. You must have your ill card whenever picking up vouchers, being certified, or redeeming vouchers at the grocery store. A proxy must have the ill card to pick up or redeem vouchers. (Refer to section below for more information regarding proxies).

2. NotifY the clinic if the ill card is lost or stolen.

3. Explain "Expiration Date" and when the participant will be due to be screened for eligibility again.

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GA WIC PROCEDURES MANUAL FY '96
4. Explain shopping procedures (i.e., review allowable items, importance of separating foods, etc.).
VII. PROXIES
A General
A person who is certified for the WIC Program and issued a WIC ID card, may designate up to two (2) persons to act as proxy.
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 (see Certification Section). A proxy should be a responsible person whom the participaiitlparentl guardian/caretaker trusts and whenever possible, should be another person in the same household as the participant.
Ifa 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.
B. Reasons for Proxies
Examples of reasons for designating a proxy include:
I. illness, 2. Imminent or recent childbirth, 3. Inability to come to the issuance site during business hours, and 4. Other extenuating circumstances.
C. Authorization
Proxies must be authorized by the participant or parentiguardian! caretaker. When a proxy is designated, the participant or parentiguardian! caretaker must have the proxy sign hislher name in the designated space on the WIC ID card in their presence (refer to page FD-IV.G.2.a.(3) if a proxy is unable to write).
D. Voucher Pick Up, Issuance, and Use
In order to pick up WIC vouchers, the proxy must have the participant's WIC ID Card.
During issuance the proxy will sign (refer to page FD-IV.G.2.a.(3) if a proxy is
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GA WIC PROCEDURES MANUAL FY '96
unable to write):
I. Each voucher. 2. The computer voucher register (when applicable).
Picking up vouchers for a participant does not mean that the proxy must redeem the vouchers at the store. The proxy, participant, parent/guardian! caretaker, or a second proxy may redeem such vouchers. Before a proxy redeems vouchers, he/she must be instructed in proper redemption procedures. The participant or their parent/guardian/caretaker is responsible for instructing their proxy(s) and need to be informed at the initial certification appointment that this is their responsibility. Proxies must also be informed of their right to complain to the clinic about improper vendor practices.
E. Restrictions
1. ~ A proxy must be at least sixteen (16) years old. Proxies younger than age sixteen (16) should only be allowed in specific instances where there are unusual circumstances. To authorize a proxy younger than age sixteen (16) approval must be obtained from the District WIC Coordinator or designated certified professional authority (CPA) and documented in the participant's health record.
2. Staff. Any health department staff, as well as volunteers working for the health department, may not receive or redeem vouchers as proxies for participants.
F. Participant Instructions
When an individual is certified for the WIC Program, they must receive an explanation of what a proxy is, how they function, why they are important, the importance of choosing responsible proxies, how to authorize a proxy, and their responsibility for instructing proxies on the proper procedures for voucher redemption.
VDI. MAILINGIDELIVERY OF WIC VOUCHERS
A. Conditions for MailinglDelivering 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. Ifvouchers are mailed to a participant for hardship reasons, they will be mailed/delivered on a temporary/short-term basis. There should not be a standard, on-going reason (i.e. permanent difficulty accessing the cIinic(s) for mailing/delivering vouchers to participants).
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GA WIC PROCEDURES MANUAL FY '96

2. Vouchers must not be mailed in the following situations:

I. Participant due for recertification.

2. Participant due for Nutrition Education.

3. Participant unable to offer a current address (i.e., homeless shelter

participant).

.

3. Prior to mailing vouchers, approval must be obtained by the issuing professional from the WIC Coordinator or a designated CPA. The designee name and written approval must be on file in the form of a local agency policy memorandum. In instances of delivering vouches to a participant, the issuing WIC professional must obtain prior approval from the WIC Coordinator, and a copy ofthe page of the Voucher Register must be signed by the Participant. Once the page is signed, it must be attaChed to the Voucher Register.

4. The hardship condition and the WIC Coordinator/designated CPA's approval must be documented in the participant's health record. Once the initial hardship has been resolved, the mailing or delivery ofWIC Vouchers must be discontinued and the action documented.

B. Acceptable Reasons for MailinglDelive~ingVouchers

1. Difficulties of the participant and his/ber proxy in obtaining vouchers for reasons such as illness.

2. Imminent or recent childbirth.

3. Appointments to pick up vouchers do not coincide with the print cycle.

4. CertificationlRecertification appointments do not coincide with pick-up. A change should be made in order to facilitate that the two are kept together.

C. Reasons for MailinglDelivering Vouchers (MASS MAILINGS)

I. Environmental crisis as a result ofa tornado, hurricane, flood snow storm, ice storm, exceedingly high heat.

2. The participant receives their primary health care from a private physician and a second nutrition encounter (class or care plan) has been added.

3. The participant does not have a clinic appointment or need follow-up and a second nutrition encounter (class or care plan) has been attended.

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GA WIC PROCEDURES MANUAL FY '96
4. The participant works during regular or extended operating hours, does not have a scheduled clinic appointment, does not need WIC follow-up and has attended a nutrition education class.
5. The clinic will be closed for holiday or other appropriate reason.
NOTE: * If the Food Stamp Program has discontinued or does not routinely mail Food Stamps Coupons to a geographical location, WIC Vouchers can not be mailed in this area.
The Local Agency must submit a detailed plan to the State Agency for mailing/delivering vouchers for a one time approval. This request must include at minimum: the reason(s) for mailing/delivering, documentation process, accountability and security of couchers and mailing procedures. The State Agency will respond to the plan within ninety (90) days of receipt of procedures. After receiving the initial approval from the State WIC Office, Districts will only need to submit procedures in cases in revisions or modifications to the original plan.
D. Mailing Procedures
The procedures for mailing vouchers are as follows:
1. Confirm valid certification. 2. Confirm the mailing address. 3. Give the participant their next appointment. 4. 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 someone other than the staff person who prepared the vouchers for mailing. 5. Someone other than the staff person(s) who prepared and mailed the vouchers must pick-up returned vouchers from post office boX; and must note on the mail roster the participant's name, identification number and sequence of voucher numbers returned in mail and full signature of person documenting this information.
6. A roster must be maintained on a weekly basis noting all vouchers mailed and participant names and identification numbers. (See Attachment 16).
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GA WIC PROCEDURES MANUAL FY '96
E. Voucher Mailing Process
When mailing vouchers the following process must be followed:
1. Vouchers must be delivered by certified mail. Labels can be used on the envelopes and all envelopes must be sealed.
2. Envelopes are sealed and delivered to the mailing area by the postal service as customary.
3. The computer voucher register or voucher copy must be documented as to the disposition ofthe vouchers. The issuing professional must document the signature line(s) with the statement "mailed vouchers" or "delivered vouchers", the reason(s) for mailing the date mailed and the full signature of the person preparing vouchers for mailing.
F. Returned Vouchers
When vouchers are returned by the postal service, the steps below must be followed:
1. Ifthe voucher(s) are still valid for redemption, the local agency will attempt to contact the patient in an effort to issue. This contact must be recorded in the client's record. Ifunable to contact, "void" the voucher(s) immediately and maintain on site until scheduled time that they are mailed to the bank, except mamIal vouchers which are returned to Data Processing. Ifrecord of manual voucher has been sent to them, manual vouchers must be voided and sent to the bank.
2. If out of date, stamp voucher register and food instrument "void", Note on Voucher Register "returned by postal service" at corresponding voucher numbers and maintain on site until scheduled time that they are mailed to the bank. Voucher(s) should be "voided" immediately and processed as customary.
G. Replacement of Mailed WIC Vouchers
1. As customary, it is a district option whether returned vouchers can be replaced.
2. Mailed vouchers not received by the participant can only be replaced one (1) time per certification period. Once the participant reports that they. did not receive the mailed vouchers, on-site pick-up is a must until a correct address is confirmed. (See Prorating Vouchers FD-XII).
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GA WIC PROCEDURES MANUAL FY '96 H. Monthly Report:
If vouchers are mailed, a report must be completed monthly to document the following: (See Attachment 16).
1. Number of vouchers issued. 2. Number of participants that vouchers were mailed. 3. Number of vouchers issued to replace reported lost vouchers. 4. Redemption value of vouchers reported lost that were eventually paid.
Monthly Report on mailed vouchers must be sent to the District WIC Office, reviewed and maintained by the District WIC Coordinator. This report should be sent to the District Office by the fifth working day of the month.
IX. VOIDED VOUCHERS
i i i vouchers should be marked "void" ifthe
o
Examples ofVoided Voucher include:
I. The participant is being suspended or terminated. 2. The participant is moving. 3. The participant has picked up vouchers and is returning them for some
reason. 4. Vouchers are prorated due to late pick up - Vouchers that are prorated due
to late pick up, must be "voided" at the time a participant picks them up. In general, any unissued voucher should be regarded as a voided voucher.
A
I. Computer printed vouchers are voided in instances such as the following:
(a) Participant is not eligible to receive vouchers (e.g., participant has been terminated or suspended from the Program),
(b) The vouchers contain incorrect or outdated information,
(c) Vouchers are damaged,
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GA WIC PROCEDURES MANUAL FY '96
(d) Vouchers are returned unused by a participant (e.g. participant is moving).
(e) A food package is tailored due to late pickup by a participant.
(f) Mailed vouchers are returned to the clinic
2. In voiding computer printed vouchers, clinics must:
(a) Stamp or write "VOID" on the appropriate signature line of the computer voucher register ifthe entire set of vouchers is voided. The word "void" may not be abbreviated. If less than an entire set is voided, the nwnber(s) of the voucher(s) voided must be circled on the voucher register and "VOID" must be written near the numbers.
(b) Stamp or write "VOID" on the face of each voucher.
(c) Package the vouchers securely to prevent breakage and send them directly to Bank South by noon of the sixth (6th) workday of the following month. Never staple a voided voucher to any other voucher.
(d) Voided vouchers must be securely stored according to program procedures (see FD-XIV) until they are forwarded to the ADP contractor.
B. flllf.Manua! Vouchers
Manual vouchers, blank or preprinted, will be voided in the instance of a misspelled participant's name, entering any incorrect information, damage during issuance, or if returned unused by a participant.
1. Voided Manual Vouchers Which Were Reported to the ADP Contractor as
lm!l:.d.. The system contains an issue record which must be voided. To
accomplish this void, the clinic should return the original voucher to Bank South (if possible) stamped "VOID." The ADP Contractor will input this voided voucher information into the system to void the issue record when it is received from Bank South. If the original is not available, the Lost/StolenJDestroyed Voided Form must be used to report the void to the ADP Contractor.
FD-28

GA WIC PROCEDURES MANUAL FY '96
2. Voided Manual Vouchers Which 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) 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 page FD-V.G. for information on batching manual voucher copies. Although there are no issue records on these vouchers, the ADP Contractor will input this void information into the system to identify the disposition of the vouchers.



PRORATED VOUCHERS

The objective of prorated vouchers is to ensure that participants receive benefits for which they are entitled to for a valid time frame. Vouchers are issued based on the number ofweeks within a valid redemption time period. A voucher is valid for only 30 days from the date of issuance. When it is determined that a participant cannot redeem vouchers within the valid time frame, the number ofvouchers issued must be prorated.

Prorating is the partial issuance ofvouchers by retrieving one or more vouchers from the designated voucher series. Vouchers may be prorated when:

(I) a participant is late picking up voucher (procedures for voiding vouchers must be followed as outlined in IX.B. Voided Vouchers)

(2) vouchers are replaced as the results of damagellost/stolen or destroyed, change in prescribed food package or agency error. Note: The procedures in Section FD-XVI must be followed when replacing vouchers.

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GA WIC PROCEDURES MANUAL FY '96

To ensure consistency when prorating voucher the guidelines below must be followed.

Women & Children

Infants

Less than 7 days

full package

full package

7-13 days late

3 vouchers issued (3/4 package)

full package

14-20 days late

2 vouchers issued (1/2 package)

1 voucher issued (1/2 package)

21-31 days late

1 voucher issued (1/4 package)

1 voucher issued (1/2 package)

Note: Ifa scheduling error is made by the clinic which results in the loss of
vouchers by the participant, one (1) or two (2) options must be used Ei(her issue entirefoodpackage andfollow procedures noted above, or change the pickup code and submit to the ADP Contractor.

Special Note: Addendum - Alternate Food Package (See Attachment FD-19). This form will be issued with the Rights and Obligations and I.D. Card.

XU. LATE PICK:UP OF VOUCHERS

Depending on how many days late they are, participants who are late picking up their

vouchers must be issued a prorated food package. If partici

me in for their

vouchers after they have been returned to the ADP Contractor as

, they must be

issued manual vouchers which bear the issue date and other dates as they appeared on the

computer printed vouchers. The food package must be tailored to reflect the period of

time left until the participant's next scheduled pickup date.

To determine the number ofdays a participant is late for pickup, the following guidelines must be followed.

1. Count calendar days, including weekends.

2. Ifthe 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.

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.

Appointment date must be documented on the voucher register in addition to the required pickup date.

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GA WIC PROCEDURES MANUAL FY '96
For example, Jane S. is scheduled to pick up her vouchers on February 27 (First Day to Use" is February 27) but does not come in until March 16. The computer printed vouchers were returned, therefore, manual vouchers will be issued and must be tailored to approximately half ofthe original package. When completing the manual vouchers, the "First Day to Use" is February 27 and the "Last Day to Use" is March 27.
To tailor voucher issuance for late pickup follow procedures for prorating vouchers. (FD-XII)
An option to prorating voucher(s), when a participant is late picking up voucher, is to change the pick up date. The pick up date is changed to the date the vouchers are picked up. A full set of vouchers is issued with the current date. To use this option the clinic staff must:
(1) document appointment date change on the voucher register
(2) complete a TAD to change the pickup code and submit to the data processing contractor
(3) stamp the voucher "void" immediately if it were necessary to void any of the computer generated vouchers
(4) Give the participant an appointment for next month's pickup for the new pickup date.
Xill. SECURITY OF ISSUANCE MATERIALS
A WIC Vouchers (See QI Section)
B. WIC Program Stamps
1. 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. WIC Program stamps must be stored in a location separate from WIC vouchers, I.D. cards and VOC cards.
C. VOC Cards
1. VOC cards 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. VOC cards must be stored separately from the VOC card inventory.
FD-31

GA WIC PROCEDURES MANUAL FY '96

XIV.

REDEMPTION OF WIC VOUCHERS
Participants/proxies exchange WIC vouchers for supplemental foods at partJ:cipating grocery stores. Only those items which are authorized on the face of the voucher may be purchased. Clinic staff must explain checkout procedures to participants and their proxies (ifthey have accompanied the participant to dinic) so that they fully understand their responsibilities regarding the use ofWIC vouchers.
A. General
1. Participants or their proxy must have their WIC ID card with theIfi. 'They do not need to have any other ID.
2. It does not cost anything to use WIC vouchers. Under no circumstances will participants/proxies get change or be required to pay anything.
3. A participant does not have to purchase everything on each voucher. However, all the foods on a voucher the participant wants to purchase must be purchased at the same time. Participants/proxies may not get rain checks.
4. Food must never be returned for cash or credit.
5. Proxies must be properly educated before being allowed to redeem vouchers.
B. Checkout
Before food prices are rung up by the cashier, the participant/proxy must:
1. Separate WIC foods from other items to be purchased.
2. Advise the cashier that WIC vouchers will be redeemed.
C. Cashier Validation
Before accepting WIC vouchers, the store cashier must make certain that:
1. The WIC ID card has valid signatures.
2. The vouchers are valid. Participants have thirty (30) days from the "First

FD-32

GA WIC PROCEDURES MANUAL FY '96
Day to Use" in which to redeem the vouchers.
3. The types and quantities of food being purchased are the same as those prescribed on the vouchers.
4. The vouchers have been pre-printed with the Georgia WIC Progr~ stamp.
5. The vouchers have not been altered.
6. The exact purchase price is entered on the voucher.
D. Voucher Signatures
The participant/proxy will countersign each voucher in the cashier's presence. If the signature on the vouchers does not match the signature on the WIC II) card, the cashier may not accept the vouchers and must immediately notifY the clinic of the situation. Participants must be instructed not to countersign until the cashier has written in the total cost of the foods. If a name has been signed in the counter signature block then the grocery store must obtain a signature above the presigned name.
Ifthe participant/proxy is unable to write, he/she must present the WIC II) card and enter his/her mark on each voucher. The cashier must initial each voucher to indicate that he/she has witnessed the participant/proxy's mark in lieu of a countersignature. The cashier may not accept vouchers unless the first mark has also been initialed by the clinic.
XV. REPLACEMENT OF VOUCHERS
When issuing replacement vouchers, the food package must be reduced in proportion to the amount of time remaining before the next schedule pick up. The replacement of vouchers must be documented in the participant's health record.
A. Lost, Stolen, Damaged, or Destroyed Vouchers
The replacement of lost, stolen, or destroyed vouchers is at the local agency's discretion. If a local agency elects to replace lost/stolen/destroyed vouchers, steps must be taken to ensure that the policy is implemented consistently in all clinics and with all participants. The following must be implemented:
1. Ifvouchers are stolen, the participant must bring a copy of the police report to clinic prior to issuing replacement vouchers. If vouchers are destroyed, any pieces of vouchers that can be salvaged should be brought to clinic.
FD-33

GA WIC PROCEDURES MANUAL FY '96
2. Procedures in QI Section x.B. must be followed for lost, stolen, damaged,
or destroyed vouchers.
3. An individual's vouchers may not be replaced more than one (1) time in an issuance period.
B. Change ofFormula Order
In the event that a formula order is changed after a participant has been issued vouchers for an original formula order, replacement vouchers may be issued. When vouchers are replaced within the same month of original issuance, the following procedures must be implemented:
Standard Formula Special Formula
I. Participant must return unused formula to the clinic ifavai1able, and!or
2. Return unredeemed voucher(s) to the clinic for voiding.
3. Supplemental vouchers issued must be prorated for the remainder of time in the issuance period.
4. Document amount, type, and disposition of formula returned to clinic on voucher registry and in health record.
Hospital Based Formula
If a formula is changed by a physician the participant must return all unopened case(s) of formula to the clinic.
The Clinic must then:
1. Issue supplemental vouchers prorated for the remainder of time in the issuance period.
2. Document amount, type, and disposition of formula returned to clinic on the Voucher Register and in the participant's health record.
3. Document formula change and receipt of an updated written or verbal order from the physician in the participant's health record.
4. If the formula is ordered by the Office of Nutrition, all unopened cases of formula will need to be returned to the company. Call the Office ofNutrition to request a return of the unopened cases of formula within seven (7) working days.
FD-34

GA WIC PROCEDURES MANUAL FY '96

XVI. AUTOMATED SPECIAL MANUAL VOUCHER SYSTEM

An Automated Manual Voucher system is currently in place statewide. This system requires that a local agency have a computer and a printer, which most agencies followed the suggestions for equipment specifications outlined in FD-XVllI..

The computer is programmed to print the required vouchers, including specific food messages. The advantage of this process is the speed and accuracy of the information printed and the ability to create any food packages presently provided by the Georgia WIC Program.

The local agency must receive prior approval from the State WIC Office and the Regional USDA Office for purchases of ADP equipment ifWIC funds are to be used, solely or partially, to purchase the equipment (see Administrative Section).

Note:

XVII. AUTOMATED SPECIAL MANUAL VOUCHER SYSTEM EOUIPMENT

In order to participate in the Automated Manual Voucher System, the equipment listed below must be purchased:

Hardware

The stand alone hardware that the interim ATVS system will be installed on is ffiM compatible 386 or 486. The minimum specifications are;

Operating System Speed RAM: Hard Drive: Monitor: Printer:

DOS 5.0 16MHZ 2 megabytes 40 megabytes VGA 24 Pin, wide carriage, dot matrix Okidata Microline 391 recommended

These specifications are adequate to the need for a

v

s. When WIC is incorporated into

then this hardware will become the WIC workstation(s), operating

file server.

Software:

Operating System: Applications Software: Database library:

MSDOS orffiMDOS 5.0
"e"
Codebase - A third party library that provides data

FD-35

GA WIC PROCEDURES MANUAL FY '96

Network:

management and user interface tools

The IJI!!system will feature the necessary file and record locking commands and operate

under Netware 386 using IBM Token Ring and Type I cable. The appropriate program

development cost for the LAN on is $20,000. Hardware and nonapplication

software costs are associated with

and are the responsibility of the State/County.

Conversion and maintenance if central processing authority plans to change application, operating or database management software.

In the event that changes W01,J~4J:Jemade to any of the software currently prescribed, it
would probably only apply to!II~I. Therefore, the ATVS would not be impacted, and
could continue operating unchanged since it has no interfaces other than the WIC ADP r which is limited to ASCII files. In the future when ATVS is integrated into
the State WIC Office may have to address such software conversions, and it has been considered. It is not in Georgia's best interest however, to do nothing, but rather create the ATVS program modules in a straightforward, fully documented manner that facilitates conversion should it be required.

XVIll. ESTABLISHING CLINICS/CLINIC CHANGES

The State Agency is required to report all clinic changes to the Southeast Regional Office. The Regional Office must be notified of cllange within sixty (60) days ofthe date which the change occurred. In order for the State WIC Office to comply with the Regional Office requirement, all Local Agencies must submit clinic changes to the State WIC Office within thirty (30) days of the date the change occurs. New clinic site information must also be reported to the Regional Office within the specified timeframe. Clinic changes are reported using the "Request for Establishing New Clinic/Clinic Changes" form (Attachment FD-15). The form must be completed and forwarded to the State WIC Office when there is a change in clinic address or a request to establish a new clinic site (Attachment FD-15). The form must be submitted to the State WIC Office within the specified time as stated above.

All Local Agencies must utilize the following procedures to establish new clinic sites:

I. A Local Agency wishing to establish a new clinic must contact the State WIC Office in writing or per telephone.

2. The State WIC Office Systems Information Unit will forward to the requesting agency a Request to Establish New ClinidClinic Form within five (5) days from date of request.

3. The Local Agency completes the form (see Attachment 16) and returns it to the State WIC Office.

FD-36

GA WIC PROCEDURES MANUAL FY '96 4. Upon receipt of the completed form, the Systems Information Unit verifies the information and forwards the form to the data processing contractor within five (5) days from date ofreceipt. 5. The data processing contractor assigns a number for the new clinic site. If the Local Agency selects its own new number, the data processing contractor must veritY and approve the number before it may be considered a valid number. 6. The data processing contractor mails the new clinic the supplies necessary to start clinic operations (ie TAD, Vouchers, etc.). 7. The State WIe Office will make a site visit and provide technical assistance, consultation, and training to the Local Agency in start up procedures.
FD-37

GA WIC PROCEDURES MANUAL FY '96
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~Q.C:
~~:

...0
lI'

2:;:l::~ ~!gl~

0 0
c

[B
r-;-;'\
:~Hi:
l~:~

~

":'>:::em0>

5
~

!mZ:::ex_>J

"~:"i>E

0

c%O-

f-c
Z::xJ

:DO

l::e>

...O:~;:::>x:J:

I

egng

0;

Ul~

CO

-J

i

o~ "~'8z
0<"!!!:Jl
"-<' c~

cl~
cO<
",0
"'~

..$
0co.<, "m'0..
-<

FD-45

GA WIC PROCEDURES MANUAL FY '96 VOUCHER CREATE CALENDAR

Attachment FD-5

CYCLE 1 1st -14th
CYCLE 2 15th - Month end

1-Cycte 1 TAD INPUT CUTOFF (15th day) 2-Date Federal Express shipped VOUCHERS ARRIVE at DIU (22nd d, 3-ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic
4-Cycte 2 TAD INPUT CUTOFF (last workday of each month) 5-Date Federal Express shipped VOUCHERS ARRIVE at DIU (7th da' 6-ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic
FD-46

GA WIC PROCEDURES MANUAL FY '96 VOUCHER CYCLE PACKING LIST

Attachment FD-6

p""e 60
~200('

ST"T O~ ~EOR'IA WIC SYSIE~

VgUCH~. CYCLE PAC~lN' LIST CLINIC)

rO~ lH~ SECOND CYCLE OF

~~lY

CUNIC .. D/U/CL

"~ Ge.

.

.

.

2 ..

~UH ~"T~ 07/0~/9~

DISTR16UT101~:

(v-;.CLINIC ~EEPS T~P COpy

CLINIC RETURN SECOND COPY TO DIST~lCT/UNIT

\,:lUCHER R~.. I~ltf( f"S ~!io8 - 1!>6t>

(~ COMPUTE~ PRI,rrEO V~UCH:R FROK ~006~~1 TO ~008~99

IF Tn: ACT~A~ C~~Tc~T~ Of TH~ SHIP~NT CIFFE~ FRO~ T~lS P"C~INv SLIP9 (::I'TACT i:.lJS-"lC IMEDIATEU. lELEPHCkE - 1-800-ZZ1-9162.

CONTEHTS VERIFICATION

---- ------- -------------

wiC REP~~SEHIATlvE Sl~H"T~RE

DATE

CO"l'tENT~

EOS SHIPpn" USE

HU~~=P. vF rlEClS THIS DlSTRlCT/UhI~

EOS ~~4LITY C~HTRCL INITIALS --~----~--.------

FD-47

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-7

COMPUTER PRINTED VOUCHER REGISTER

....... PAC;E tl21

nAft 01' CEOIU:IJ. VIC nnnc "C.O..r.i.P..c.n~1D~ ~ftD VooaDt u:a;XSTD

'O:c In

PAJtnCXI'AXT 1U.XE

- rAKnY

C I' un

(TE:LI!:!'IIOll2:1

rxltST voaaa::Il IfIMaUS

IS' 001 '11'

1l.0lU1D

(

J 053.'" 053.'" 0534'" 053.'"

1 c 1 ~.~ I

4

~ ~ _ 02/1.1'2

01/0'/'2

IS' 001 '21 ,
(

4 1

OS3467C

053.'11

1l.0fUU)
053."2 OS1."3

4

1

C3

1 /

~ ~ _ 02/14/'2

02/12/'2

1St 002 12. , 3

(

J

053.".

053."5

IlXCUU
0534'"

051.'"

4

K

CJ

....................11
01113/12

- IS' 002 071 1 2

(

J '53.'"

OS3.'"

JUn 0534"0

051."1

4

~

C3

1 1 0110'/12

- 15' 002 071 3 3

Q<W(a1ll.

- (77' 25") 053.612 0534613

X % 2 1/

2

0110"'2

1St 000 "2 5
... ('" 002')
IS' 002 U, 1 1 (000 0000)
1St 002 '17 1 3 ('" '515]

wn.Ln:
0534614 0534615 053.'"

M~C ~ 11

051461' 4

~ ~ _ 01/22/'2

01/01/'2

053.'"

053.61'

OSCAJt
053."0

0514"1

4

1

c3

11 01/0'1'2

- UAZ:I.
-053."2 053."3

1 %2 / /

2

~ ~ ASSZSSKEX% - 01/0'/'2

01/0'1'2

1St 002 000 ~ 4

COOkIhEJ

Mel 1 1

(

J 053.". 0534"5 053.'" 0534'" 4

~ ~ - 01/11/'2

01/0'/'2

IS' 001 752 , 1 ~

~

1 1 1 /

C'" 0.131 053."1 011.'" 0534'00 0534'01 C

01113/'2

FD-48

GA WIC PROCEDURES MANUAL FY '96 VOUCHER REGISTER SUMMARY PAGE

Attachment FD-8

DIU - 01-1

"An: OF GrO~u. VIC n'sn:JC
COfaUlLA c::o:I:JtI.Tz:z) vooa::a. UGlnz:Il

CUIVT 01-1
~UK CAT[ 12/11/'1 !~7~ CUTOTr nkTt 12/1]/'1

1'2 In acuz: - ~rrt
'2 u.aJa' OVDU1: (7) - KH/DDrrt
~ ~ (7~ 2) - KH/rmrrt

FD-49

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-9

TRANSMITTAL FORM

Verification

Receipt ofWIC Vouchers

Clients's Name

' Clinic -----------

This is to certify that I received the following WIC vouchers:

:I#I

:11 #_-------------_-

Participant/Proxy

Date

StafffInit.

Date

TRANSMITrAL FORM

Verification

Recelpt ofWIC Vouchers

aients's Name

- Clinic -----------

This is to certify that I received the following WIC vouchers:

# #

##__----------------------------

ParticipantfProxy

Date

StafffInit.

Date

Oients's Name

TRANSMIlTAL FORM

Verification

Receipt of WIC Vouchers

Clinic'-

_

This is to certify that I received the following WIC vouchers:

:##

## __ -- -- -- -- -- -- -- -- -- -- -- -- -- --

ParticipantfProxy

Date

StafffInit.

Date

Oients's Name

TRANSMITrAL FORM

Verification

Receipt ofWIC Vouchers

Clinic'--

_

This is to certify that I received the following WIC vouchers:

:/#I

# # _ - - - - - - - - - - - - -_ -

Participanl/Proxy

Date

StafT/lnit.

Date

FD-50

GA WIC PROCEDURES MANUAL FY '96
FORM AND MANUAL VOUCHER 1~F.1_I:::

Attachment FD-l 0

GEORGIA WIC PROGRAM FORM AND MANUAL VOUCHER SUPl'LY ORDER FORM (REV U9S)

I

Return to:

Viking Computing. Inc. 1000 Nonh Madison Ave., Suite W-ll Greenwood. Indiana 46142

Phone: 1-800-899-7913 FAX: 1-317-889-9485

Your DistrlctlUnit: Clinic name:
Address:

This order is for clinic #:' - - -

Contact person: _ _ _-,-

Pbone:

DateMailed:

_

Nom: Viking processes Georgia WIC Program orders twice a month. Orders received at Vtking by the 10th of the month are processed so that the order is delivered by the 25th of the montlt Orders received at Viking by the 25th of the month are processed so that the order is delivered by the 10th ofthe following month. Ifthe 10th or 25th fall on tho weekend or holiday. the cut--offis the workday before.

MANUAL VOUCHER ORDER
BLANK MANUAL VOUCHERS FQRHAND COMPLETIQH
_ _ Blank manual voucher (no tuna or earrofsJ_ _ 408 (blank manual voucher with tuna arad carrots)

PREPRINTED MANUAL VOUCHER PACKAGE SETS FOR HAND COMPLEUON
_ _ Sets ofprenatallbreastfeeding women package 404 _ _ Sets ofpostpartum non-breastfeeding women package 502 _ _ Sets ofinfant package 113 _ _ Sets ofchild package 603

SPECIAL MANUAL VOUCHERS FOR USE ON COMP~
_ _ Special manual vouchers for use on computer (ATVS. MVS. M & M, or other State approved system)

CERTIFICATION FORM CfADl6RDER
_ _ Blank TAD (no preprinted 10 number) _ _ Prenumbered TAD (preprinted II) number)

OTHER FORMS
Form and Manual Voucher Supply Order forms Lost/Stolen/Destroyed Voided Voucher Report forms Vendor Input Form

FD-51

GA WIC PROCEDURES MANUAL FY '96 MANUAL VOUCHER INVENTORY

Attachment FD-ll

~

~-a.

DDDIe: 110. -a. asc::uYKD .-a. ~ -a. Qt~ -a. ow aAKD 1.tnAU
-~

.

FD-52

GA WIC PROCEDURES MANUAL FY '96 BATCn CONTROL FORM

Attachment FD-12

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

DISTRICT/UNIT

CUNIC

BATCH CONTROL FORM

DATE

NUMBER

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TAOS (CERTIFICATIONS. UPDATES, TRANSfERS AND TERMINATIONS) AND ISSUEDNOIOED MANUAL VOUCHERS.

2. DO NOT BATCH TAOS WITH MANUAL VOUCHERS.

3. DO NOT SUBMITVOIDEDIUNCLAIMED COMPUTER VOUCHERS TO VIE::tNG.

INSTRUCTIONS

~. SUBMIT THE 1ST AND 2ND COPIES OF THIS fORM AND ACCOMPANYING MATERIALS TO: VIKING COMPUTING, INC. P.O. BOX25~ GREENWOOD, IN .61'2-25~

VIKING INPUT SECTION

S. RETAINTHE3RDCOPY OF THIS FORM INTHECLINlCWlTHCOPlES OF THE TAOS

OR MANUAL VOUCHERS, CREATING A BATCHCONlROLMODULE-

TYPE OF DOCUMENT

NUMBER IN BATCH

TURNAROUND

COMMENTS:

VOIDED MAffiJAL VOUCHERS

DATE SENT BY DISlRICT/UNIT DA1E RECEIVED AT ViKING DATE ENTERED AT VIKING

PRE PARER'S SIGNATURE SIGNATURE SIGNATURE
FD-53

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-13

BATCH CONTROL EXCEPTION REPORT

I

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

VOUCHER BATCH EXCEPTION FORM

DISTRICT! UNIT

CLINIC

DATE

NUMBER

:

I

THIS FORM HAS BEEN GENERATED AS A RESULT OF:

-~

THE QUANTITY ON THE CLINIC COMPLETED BATCH CONTROL FORM DOES NOT AGREE WITH THE ACTUAL QUANTITY RECEIVED.

THE VOUCHERS WERE RECEIVED IN A BATCH OF TAOS.

ONl.Y- ONE (1) COpy OF THE BATCH CONTROL FORM WAS RECEIVED WITH Tf1E VOUCHERS.

NO BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.

VIKING INPUT SECTION

TYPE OF DOCUMENT ISSUED MANUAL VOUCHERS VOIDED MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

.;=.:= :~7: 3':'-':-

0.=: ;.- ...~

FD-54

-"'t
~
t1
]
t)
~
\0 0\
~
~
~
r:n
~

~
u
~
~
~

SHOPPING HINTS

Use your W1C vouchers to gel the foods lisled on lhe

fronl of the vouchers. They are nutritious foods, good

~.

for you and your baby's health.

~,

AI (he chcck--oul counterI tell lhe cashier thai you are using WlC vOUCheD. You or your proxy (person(s) you

z!

choose to use your vouchers) musl show (his ID folder.

o

Remember your proxy must be al Icast 16 years old.

u~,

Scpanllc your WTC foods from other foods you are buying. Each voucher is a separalc order.

5

Do nol pay money for WIC foods or exchange WIC foods for other foods or money. Do not accepl money

~,

from cashier.

~
S

If you have problems buying W1C foods allhe slore, ask the Slore manager for help or call lhe Slale WIC Office at lgoo.22g9173 toll free.

~

Use WIC vouchers on or after the "Fint Day to

~I

U~c" date and on or before the "Last Day to UK" date.

~

Sign Ihe voucher on the righl side afler the correct amounl is written in by the cashier.

~ Use your vouchers in siores that have the "We

~

Welcome WIC Vouchen" sign in the window.

~I

Do nol make any changes on your voucher(s). The store is nOl allowed 10 accept vouchers thai have been

s:
o~

altered.
Shop for Ihe besl prices! The more you save. Ihe morc people we can serve!

~.

'8'.
0.

SDTcpAllRTmEenl OofFHuGmaEnORRuoGurIcAtl
Division of Public; Heallh

WIC PROGRAM 10ENTIFlCATION CA~O

11

NOT VAliD WITHOUT
WlC
PROGRAM STAMP

PARTICIPANTS
10-- NAME
1111111111

EXP. EXP.
DATE ~

10' & NAME

1 1 I I II

II

II

10' NAME
1111111111

10' & NAME
1111111111

10' ,NAME
1111111111

AUTHORIZED PERSON:

JJJiTiCjoAH,"'NiiHlIOUAAOWl WAAT\if\I

~

Other. authorized 10 plck up vouche', and lood:

~

2.

PROXY IIGHATUAI

~
BRING THIS FOLDER EVERY VISIT
'Qf"'310~IAn. '941

BRING THIS FOLDER EVERY VISIT

APPOINTMENTS

"""'""'" .... """"'" 'AT'

""'<JI' .NouVelMoTIOlOHH

1UlSl0U<Nl' ClJImCATIOH

...... 'OUR

QtI.~RfHi

. . . .O O f t l f

"

PIQ(UPCOOE COto41olfHTS
lOC<I AOfHCY/
.C..l..~..~,
AOOfIE$$ p",,",

VOUCtlERltfTERVALGOOt::

_

_

Georgia WIC Prognom

WIC APPROVED FOODS UST

The rollowin, lis. or rOOfh mal N pu1Chased win, WIC yoochcn:

I rOOD I'T'DI CIUND wlYPQ

NOT AUOWW

I "W. MILK C~I: I CW OWl.Y

"""'

"I'.'IM.Lowf.. tJI)

C~ ANNOT

Il.cIM~""'ONL.Y)

1Ivncnlli.l

un.w. "'f~iIvlI. +1,

Got!'IMilk ~Id 100. PlifJ !tit

l~o.l. or Ql.ONl.Y)

Enp)("'" CIJ OJ. C_ Of'lLyt ........ok'NIJorJ9I. Io... ONln

Cf.Rt:AI"I'o.. fiuf_ Ak>, c.. a.li.JjuVrI","' I CANNUT IVY,

Clift,;,;;

I io,. ",itNUff 11"111

(1rw c..........~.ot w",..

efi>fJelillcn

C""IIltyC_flaln
'iIIIIh,..,IfI........ o..c-..,....o..cllt II'.~""fto ....1 DIIIOfy 0viA O,ilIll/'lll ',"il'oN)

1t,1I01l', ' Cono n.ln. Sptcilt It

Kl.

......... NIobUn) e,nlil of WM. tll,pllll flulln

' ' - ' 1 _ M i _ )

Oti_.IIJl'.~..,''''011

().Irw.-....Orillllllr fIr_1
QyaU, 1 _ Oti~ (At I" "lIYOII TfQ/'Cgn

CHEESE: .,. 01. II .1 Sim GNUI

AfNric'.. ISI~ ......,)

C1ledoWltiodl

CGh7ltlc>ckl

MOIIIrf'fJ'M'I,*'~ Mouw,ltoilloc'.

K,.,'t()rhlwISlin4411SU1.I,W,apfflll

"ilMlIlI JUICElllOOI USlOA

C f'ot\irlld.

46 Of. C'_ Of IJ OJ. 'rou. eMf ONL".

OlANO!: lAuIllfI"Il... InN OHLY
o....nllurr: LWolIyrMI... tnrwI ONI-Y
GIAn: W,ldI. -1I/kJ JvIf'1

A'"-!: fIr__

KfOtH

Lo.drLc.r

Setrr

~.WUW(Wy1

ShulfiAr'

Tlrorih,W.W1

Vo1lOIrHw ...

OTHU:Ouk~

Oc'IIr~Ja.

Mr,JIIiA:nrnr

Mr)''''~'''-''

lvinlvlrtT......

aCA-NwN,O.T..'VV. ....... a-w
o.lia.e-

A. . . .0,1..

Plp. b 01. or

$mHitlOl.,l...."...'...

CANNOT IVY.
Nk-IDri<ll1
'tf.aa~hit. Si".knillp l.t""wirn lvicn.idIs........4W

EGGS: 10rldr A wI!. I Or. Siu ONl.Y) UNI E0r-/':! InIII1 ONLy

CANNOT IW. "'111 OlJw,Siu/QIIIllllirY

A.'....., DRIED PEASIBEANSr II 1If. Siu ONl.Y) W~ h.:orl:t Added
PEANUT II.IlTERt til OJ. J.,. ONLV) ...., ...... W'00ur hi'" or

CANNOT IUV.
~""
CANNOT IVY.
~Irr

INfANT fORMULAI AI lMleoIoef_olV-,"

CANNOT IVY. ~UwlOI 'lWi:olVwrhn'

INfANT CERfALA cDry.' OJ. kin ONl.y) J,rrctIN.... OrtW ...,..

CANNOT IVY,
~f""".id1

r","or'onroo"A~

Oil"'"" TUNAl '&"1 01. e... ONLY)

~

Lull !rPfll'lrc 1rW. W-, ""ClI

( f . ~_ _ "OlIft01O'1~~

CARROTSlll . "'S.rlCll ""1Iie'!It ONLYI

CANNOT IUYt

FKIIo.Wh>Ir

~-.rl.

1,. . . .IIIII1Mdint_wf'IaOllftOl0'1"""" wuctoIot>l Y1~.lWa.l'JC""",,

lrl lrl
I
Qu..

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-15

REQUEST TQ ESTABLISH NEW CLINICICLINIC CHANGES

GEORGIA WIC PROGRAM REQUEST TO ESTABLISH NEW CLlNIClQ..INICCHANGES

PURPOSE OF REQUEST

EST. NEW O-INIC

O-INICCHANGE

_

EFFECTIVE DA'IE OF CHANG"'E=--

_

TYPE OF CHANGE:.-

_

DISTIUNIT

_

DA'IE SUBMIT'IED-::-.-

_

COU!'ITY#

COORDINATOR

_

CONTACT PERSON NEWO-INICNAME MAILING ADDRESS (NOT P.O. BOX)

PHONE # CLINIC DAYS AND HOURS OF OPERATION

AT'IENTION:

PURPOSE OF PROPOSED CLINIC (circlc) ccrtification recertification nutrition edncation voucher issuIDce

other (specify)

_

SCHEDULE OF VOUCHER ISSUANCE (cir.:le) monthly bi-monthlyodd bi-monthlyeven
PLEASE INDICA'IE IFTADS AND VOUCHERS ARE TO BE SHIPPED TO ANOTHER LOCATION OTI-lER THAN THIS CLINIC.

VOUCHER ORDERS SPECIAL VOUCHERS BLANK VOUCHERS

TAD ORDERS BLANKTADS PREPRINTED TAOS

WOMEN (P&B) INFANTS

I PREPRINTED VOUCHER PACKAGES PACKAGES WOMEN (N) _ _ _ _ _ _ _-'PACKAGES CHILDREN

_ _ _ _ _ _ _ _.PACKA< _ _ _ _ _ _ _ _.PACKA<

PLEASE INDICA'IEA BEGINNING TAO NUMBER (EXAMPLE: Q..INIC #123 WOULD BE 123000001 FOR THE BEGINNING TAD NUMBER)

VIKING 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. Pl.EASE INDICATE.

YES__ NO

_

FD-56

.\.0... I
~

1:.l
j

u

~I

~I
0~I

:1
~
~D A
d;, I

Participant's Name

\.D. Number

Number of Vouchers Issued

Number of Vouchers Returned

Signature of CPA

Date

Replaced Voucher Redemption Value

Returned Numbers Lost/Stolen of Lost Vouchers

~

L

~Y

~

\Q
'i'

~.

~
~

~I
Zl
~I0 1
~'

Cll
~

~00'1

End of Month Total # of

Totals

Participants:

Date:

~I

Total # Issued:

Total # Returned:

~
u~
~

<i:3,
~

*Redemption Rate must be completed by the District Offi~e

l'-
l()
aI
~

Total # Replaced:

Total Redemption Value: $

U
I-l
~
~

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-17

PAGE 44 REPORT EWRR350G METRO-WEST HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF JUNE

1995

PART 1 NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE MAY

APRIL

NUMBER NUMBER S AMOUNT S AMOUNT

CLINIC PAGE 8
D/U/CL 03-1-335 RUN DATE 07/13/95

ISSUE DATE

TOTAL

73081198 40799437 R 3.78 73081199 40799436 R 3.82 73081200 40799435 R 7.57 73081201 40799438 R 7.63 73081215 40762857 R 5.78 73081216 42524551 R 7.03 73081217 55342037 R 11 :01 73081218 31728803 73081219 48822739 73081220 48822740 73081226 67955219 R 8.55 73081227 52174328 73081228 67955220 R 6.12 73081229 40096596 73081237 48790196 73081238 67226442 R 6.93 73081239 55272161 R 9.84 73081240 40097235 73081241 31744277 73081250 55229223 R 4.55

p- 10.15 ................................. ....... / .... / .......
R 44.26 .............................................................. . ...... / .... / ...... ,
R 38.84 ..... - ..... _...................... ....... / .... / .......
R 3.83 ................................. ....... / .... / .......
R 2.95 -_ ............... - ................. ....... / .... / .......
R 7.41 ............................................................... ....... / .... / .......
R 4.33 ............................................................... ....... / .... / ....... R 7.72 .. __ .............................. " ... ' . / .... / .......

FD-58

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-18

PAG 149 REPORT EWRR351G FULTON COUNTY HEALTH

STATE OF GEORGIA mc SYSTEM
CUMULATIVE UNMATCHED REDEMPTIONS FOR THE MONTS OF FEBRUARY 1995

CLINIC PAGE 1
D/U/CL 03-2-619 RUN DATE 03/10/95

PART 2 NOT MATCHED TO VALID CERTIFICATION RECORD

VOUCHER REFERENCE ISSUE

NUMBER

NUMBER DATE

WIC 10

JANUARY DECEMBER

FAMILY C P S AMOUNT S AMOUNT

RECONCILIATIONS

TOTAL

71728892 52948691 12/14/94 697006616 0 1 71728893 64711822 12/14/94 697006616 0 1 71728894 64711821 12/14/94 697006616 0 1 71729170 64746739 12/14/94 619601993 6 1 71729171 50916342 12114/94 619601993 6 1 71729172 63301739 12/14/94 619601993 6 1 71729173 63301740 12/14/94. 619601993 6 1 71729252 52875061 12/14/94 619602215 3 2 71729253 52875059 12/14/94 6196022~5 3 2 71729254 52875062 12/14/94 619602215 3 2 71729255 52875060 12/14/94 619602215 3 2 71729256 63385216 12/14/94 619G02215 3 2 71729357 52963679 12/14/94 619601478 8 2 71729358 52963680 12/14/94 619601478 8 2 71729359 35912204 12114/94 619G01478 8 2 71729360 41747854 12/14/94 619601478 8 2 71729363 44106698 01/11/95 619601478 8 2 71729364 44106699 01/11/95 619601478 8 2 71729739 50901965 12/14/94 619600963 0 1 71729740 64752844 12/14/94 619600963 0 1

R 4.45 R 6.85 R 4.41 R 6.97 R 6.85
R 4.42 R 7.60 R 4.79 R 12.76 R 5.56 R 6.17 R 5.78 R 4.37 R 5.89
R 10.01 R 13.71 R 8.97 R 13.80 R 8.17 R 9.64

:
...................... ~ .................................... ............................................................. ............................................................. ...........................................................
............................................................ ...........................................................
............................................................
............................. - .......

PD-59

GA WIC PROCEDURES MANUAL FY '96

Attachment FD-19

iJx1liief .................- lm_isllrmllitliilliBllnll.l

I;I~:::~ ::%:::~y$
mf~:~::~~y~:::mt~

'~'~~i:::~]::I~~I~:~Ji .:::;lgJ.~
!i"I',.llm:
4::11111111~~
i:III.'P

II~::_I.@g !I~::p~l@gi

FD-60

TABLE OF CONTENTS

I. Introduction ':. .
II. Monitoring .
m. Partici ant Abuse

. .

V. VI. VII. VIII. IX. X. XI. XII.

Guidelines for Investigating Employee Abuse ..

Procedures to Request an Employee Investigation

Vendor Compliance Investigation

.

Compliance Investigation Food Purchases

Disqualified VendorlParticipant Hardship

Lost, Stolen, or Destroyed Vouchers .

Voucher Issuance Security

.

Notification Summary of Missing VoucherNOC Cards

Attachments:

QI-l QI-2 QI-3 QIi!
g~~1
QI-;l QI-~ QI-W

Closeout Reconciliation Report

Quality Improvement Voucher Investigation Log

Participant Sample Warning Letter ...

Request for Investigation Form. .

.

WIC Transaction Report

.

Verification Form Disqualified Vendor

Hardship to WIC Participant. . . .

Georgia WIC Program Vendor Donation List. . .

.

LostlStolenlDestroyed Voided Voucher Report

Notification Summary ofMissing VouchersNOC Cards

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GA WIC PROCEDURES MANUAL FY '96

I.

INTRODUCTION

The objective of the Quality Improvement Unit is to provide guidance and assistance to Local Agencies in programmatic compliance and in the investigation of suspected fraud and abuse within the WIC Program. This area includes, but is not limited to, WIC participants, WIC clinical staff; WIC approved vendors and any other applicable WIC Program abuse which would require investigation.

ll.

MONITORING

I. On a periodic basis (not less than once per year), the WIC Program Coordinator or designee will visit each clinic for the purpose of reviewing clinical procedures, as outlined in the Monitoring Section-SelfReviews.

2. Ifthe review ofvouchers/voucher related materials causes suspicion, and the Coordinator determines that a clinical investigation is needed, the Coordinator shall notify the State WIC Office and proceed with the investigation. The State WIC Office shall notify USDA-FNS of the impending investigation and keep them informed of case progress on a periodic basis or as requested/necessary.

3. Vouchers marked VOID will be checked against the Reconciliation Report (see Attachment QI-I). This report is generated at the clinic level and gives the final disposition of all computer printed vouchers.

4. InveStigations may include review of the voucher register, voucher inventory, cashed vouchers, certification records, and if necessary, contacting WIC participants to verifY if vouchers were picked up.

5. The State WIC Office shall retrieve voucher copies when the Coordinator determines the need during an investigation. These vouchers will be reviewed by the State WIC Office for compliance, prior to being forwarded to the Local Agency. A Quality Improvement Voucher Investigation Log should be used when requesting voucher copies from the State WIC Office (see Attachment QI-2).

6. Investigative/Monitoring clinical reviews will be conducted in conjunction with the monitoring team, and when deemed necessary during an investigation.

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GA WIC PROCEDURES MANUAL FY '96

m.

PARTICIPANT ABUSE

A. Dual Participation

Dual participation occurs when individuals receives benefits twice in the same clinic, or from more than one clinic. The \V1C Program Automated Data System generates a quarterly "Dual Participation Report". The report specifies possible duplicate enrollment in alphabetic sequence. (See Georgia WIC Report Manual for details). The report data is compiled into a composite state report, and a report for each Local Agency.

The ADP Contractor mails the Composite Dual Participation Report to the State WIC Office. At the same time, each Local Agency reviews a Dual Participation Report. The Local Agency must investigate and reconcile each possible dual enrollment. The reconciled report must be submitted to the State WIC Office within sixty (60) days from the run date ofthe report. All information regarding the reconciliation must become a part of the participant's health and issuance records. Upon receipt of these completed reports, the State Agency will eliminate obvious false duplicates by:

1. Transferring all actions taken by local agencies onto the State composite report and;

2. NotifYing any local agencies that have participants whose enrollment

has not been reconciled.

.

The local agency must conduct further investigation until all alleged dual participation are 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 ifthere 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 detennine if it is the same participant or two different participants. Document all information obtained and the final action taken on each case in the participant's health and issuance records.

The current TAD field code #52 allows the system to identify multiple births. This should reduce, ifnot eliminate, twins from appearing on

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GA WIC PROCEDURES MANUAL FY '96
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 State WIC Office 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 review health and issuance records. Ifthe 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 below (participant Abuse~ and Sanctions) for procedures regarding how to proceed with this type of abuse. Documentation of all information and final action on each case must become a part of the participant's clinic file.
B. Participant Abuses and Sanctions
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 TerminationJIneligibility/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.
Before suspending a participant from the Program, the Local Agency may issue one (1) warning to the participant to try to correct the problem. A sample warning letter is included in this Section as Attachment QI-3.
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GA WIC PROCEDURES MANUAL FY '96
The maximum amount of time a participant may be suspended is three (3) months. Ifthe participant requests a fair hearing within fifteen (15) days after receiving the suspension or termination letter, they may not be suspended or terminated until the disposition of the hearing. Where participant abuse involves a woman and her infant, or child(ren), suspend ~ the woman. The infant and/or child(ren) may continue receiving WIC benefits. However, on subsequent visits, the infant, or child(ren) must be brought to the clinic by a proxy during the period of termination or suspension ofthe mother.
I. ABUSE: Participating in more than one WIC Program simultaneously (dual participation).
SANCTION: When dual participation is discovered, the participant must be removed from one (1) Program. The two (2) Local Agencies involved must agree on which Program will terminate the participant. The participant must be notified, in writing, that simultaneous participation in more than one (1) Program is in violation ofWIC regulations.
Ifthe same individual is found to be a dual participant on a subsequent occasion, he/she must be suspended from both programs for a period not to exceed three (3) months.
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, residence, diet intake, and medical history.
SANCTION: The participant may be required to pay the State Agency, in cash, the value ofbenefits improperly issued to them. The "value ofbenefits" is the dollar amount ofWIC vouchers which were issued and cashed or the cost to the WIC Program of the special formula provided through direct distnbution. 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 State Agency of such occurrence. Based upon the information received from the Local Agency, the State Agency will make a determination as to whether the misrepresentation or falsification was intentional. All facts must be documented in writing. Prior to the State Agency determination, the Local Agency shall provide the State Agency, in writing, with the following information:
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GA WIC PROCEDURES MANUAL FY '96



Copy of the front and back of the WIC

Assessment/Certification Form signed by the participant or

authorized representative.



The serial number ofallWIC vouchers, manual and computer,

issued to the participant or authorized representative within

the certification period.



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 State Agency will make a determination as to whether falsification and/or intentional misrepresentation has occurred. Ifthe misrepresentation or falsification is determined to be intentional, the State Agency will proceed as follows:



Secure the vouchers cashed by the participant from Bank

South and/or microfilm of vouchers previously cashed.



Determine the total value of the cashed vouchers.



Make a recommendation that the Local Agency take the

following actions within seven (7) days: .

a. NotifY the participant of the findings. If the investigation findings still allow the participant to be eligible for Program benefits, a suspension period of three (3) months is to be imposed. The participant will be notified, by certified mail, of his/her suspension and right to a fair hearing.

b. If the investigation findings establish that the participant is ineligible for Program benefits the participant will be immediately terminated from the Program. The participant will be sent, by certified mail, a Notice of Termination Form which includes notification oftheir right to a fair hearing.

c. Ifthe total value ofbenefits issued is less than $100, it will be documented in the participants health record. No recovery action will be initiated the first time, however, a. and b. above still apply. If the same

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GA WIC PROCEDURES MANUAL FY '96
offense occurs a second time, steps will be taken to recover all of the misappropriated benefits.
d. If the total value of benefits issued is $100 or more, the participant will be given a notice, supplied to the Local Agency by the State Agency, of the dollar value ofWIC vouchers cashed along with the opportunity for repayment. In no instance will repayment arrangements be extended beyond ninety (90) days from the date notification is provided to the participant.
3. ABUSE: Sale of vouchers or WIC food items to, or exchange with, other individuals or parties.
SANCTION: When proof of abuse has been established, the participant will be suspended from the program for a period not to exceed three (3) months. The participant must be notified ofhislher 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 (Abuse #2d) will be implemented.
4. ABUSE: Receiving cash for vouchers from food vendors, or credit toward purchase ofunauthorized 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 three (3) months. The participant must be notified ofhislher 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 (Abuse #2d) will be implemented.
The State WIC Office 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 verbal behavior and the action that will be taken if the
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GA WIC PROCEDURES MANUAL FY '96
problem continues.
Ifthe problem does continue, the participant may be suspended from the Program for a period not to exceed three (3) months.
6. ABUSE: Physically hurting, pushing, or inappropriate physical handling clinic staff, vendor personnel or property, and/or other WIC participants in the clinic/store.
SANCTION: If Local Agency staff determine 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 three (3) months.

Repayments will be submitted to the local agency and must be in the form of a cashier's check or money order Payable to: DHRlWIC Program. Any other form of repayment is unacceptable (i.e. cash, personal checks, etc.).
~II The Local Agency will immediately forward all repayments received to the State Agency for processing.
g~ If total payment is not made within the ninety (90) day timeframe, the Local Agency will notifY the State agency which will in tum proceed with recovery actions prescribed under Georgia Statute.

Collection of claims for repayment of benefits is suspended if an appeal for a fair hearing is requested.
li! The suspension remains in effect until a fair hearing decision is
rendered.

~!

If a fair hearing decision at the local level is rendered in favor of the

local agency, efforts to collect repayment must be resumed.

~l

Repayment efforts must be resumed even if the local level decision is

being appealed to the next leveL

v.

GUIDELINES FOR INVESTIGATING EMPLOYEE ABUSE

When employee intentional abuse is found, it may be considered employee misconduct. Suspected intentional abuse shall be investigated by the Local Agency with

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GA WIC PROCEDURES MANUAL FY '96

assistance from the State WIC Office, and may require a Department of Human Resource Office ofFraud and Abuse (DHR-OFA) investigation.

(Intentional abuse is a deliberate effort to defraud the WIC program (exam: illegally taking WIC vouchers; giving false/misleading information in order to become certified on WIC, etc.)

I. Employees participating on the WIC Program shall have the same rights and obligations as any other WIC participant, unless otherwise stated in WIC Program Procedures Manual or Local Agency Policy.

2. Employees participating on the WIC Program shall adhere to the rules and regulations for program participation and job responsibilities.

3. DHR-OFA investigation shall be handled in conjunction with the Local Agency.

4. Action to be taken as a resort of a DHR-OFA investigation findings, shall depend on Local Agency personnel policy and procedures concerning the employee misconduct.

5. Prosecution shall be processed through the District Attorney's Office. The Local Agency requesting an order of prosecution, shall notifY the State WIC Office and the State WIC Office sh?11 notifY USDA-FN.S.

6. The State WIC Office recommends that any employee found to be abusing the WIC Program to be removed promptly from any access to WIC vouchers issuing records without reappointment rights.

VI.

PROCEDURES TO REOUEST AN EMPLOYEE INVESTIGATION

I. The District Health Officer shall forward a letter requesting an investigation directly to the DHR-OFA and a copy ofthe letter must be forwarded to the Division of Public Health Director's Office and the State WIC Office.

2. Contract agencies requesting an employee investigation shall submit their letter to the Division ofPublic Health Director's Office and a copy to the State WIC

Office. The Director's Office shall then forward the request for investigation along with a cover letter to DHR-OFA.

3. DHR-OFA investigation results will be forwarded to the office which initiates the request. The initiating Agency shall submit the results to the District WIC

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GA WIC PROCEDURES MANUAL FY '96

Coordinator, Program Manager, District Health Director and a copy to the State WIC Office.

VIT.

VENDOR COMPLIANCE INVESTIGATION

Compliance investigations will be coordinated by the State WIC Office.

Investigations will occur at stores that have been identified as "High Risk" by the State WIC Office through the use of the ADP system reports, complaints, and the Request for Investigation Fonns received from the districts.
A Request for Investigation Fonn (Attachment QI-~) should be completed on any store the local agency has reason to believe is violatiJ:J.g WIC procedures. A copy of the Request for Investigation Fonn should be mailed as soon as possible to the State WIC Office for action.

Local Agencies that would like to conduct compliance buys in their stores must contact the State WIC Office for approval. If the Local Agency conducts any compliance investigations, each buy IllUst be documented by completing the WIC Transaction Report (Attachment QI-). The original copy of this fonn must be submitted to the State WIC Office.

Vouchers to be used by the State WIC Office in compliance investigations will be generated by the ADP system using a clinic that has been set ul? for that purpose.

The Local Agency will not be notified when investigations are in progress in their area until after the investigations are completed.

VITI.

COMPLIANCE INVESTIGATION FOOD PURCHASES

WIC foods and other food items purchased as a result of the compliance investigations, are donated to non-profit organizations within the city(ies) where the purchases are made by the investigator.

Such non-profit organizations are as follow:

*City and County Fire Department *City and County Police Department *Retirement Homes *Battered Women Shelters *Church Organizations *Boy Scouts *Girl Scouts

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GA WIC PROCEDURES MANUAL FY '96

The compliance investigator completes a Food Donation List (see Attachment QI-'gh and submits it to the non-profit organization for verification of foods to be donated. A representative of the non-profit organization will sign the donation list to confirm the receipt of foods, and may obtain a copy of the list for their records.

IX.

DISOUALIFIED VENDORIPARTICIPANT HARDSHIP

Ifa vendor is found to be in violation of Program policies and regulations through a compliance investigation(s), the vendor will be assessed sanction points for violations occurring in each investigative visit. If a vendor accumulated 25 or more sanction points, the store shall be disqualified from WIC Program participation. In the event a vendor disqualification creates a hardship for WIC participants, the State must intervene to relieve the participants hardship. Procedures and guidelines for vendor disqualification, which are a result of an investigation, are found in the Vendor Section-TerminationslDisqualification.

To assess participant hardship in obtaining WIC food as the result of a vendor
disqualification, the State must initiate the ve,gtication process. The State will complete a Verification Form (Attachment QI~ and submit to the Local Agency Vendor Coordination. The use of the "Verification Form" is two-fold: (a) to verify if a disqualified vendor's absence will create hardship for WIC participants; (b) to
verify that there is no participant hardship in case of future administrative/judicial
hearings. Verification of participant hardship will be in accordance to hardship procedures as stated in the Vendor Section-Probation Period ~d Hardship Cases,

The District Vendor Coordinator shall verify participant hardship cases based on regulations in the Vendor Section-Probation Period and Hardship Cases. Once verification is completed, the Vendor Coordinator shall return the original completed form to the State WIC Office within ten (10) working days.

Ifindeed the disqualified vendor creates hardship for participants, the state will resend the disqualification within fifteen (15) working days from receipt of the verification form and award the vendor a probation for the same time period of disqualification. The probationary period is contingent upon the vendor's total compliance with all Program rules and regulations. Should the vendor violate Program rules and regulations during the probationary period the vendor shall be disqualified from the Program. (See Probation Period and Hardship Cases in the Vendor Section.

x;

LOST. STOLEN. OR DESTROYED VOUCHERS

A. 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:

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GA WIC PROCEDURES MANUAL FY '96

I. Complete the LostlStolen/Destroyed Voided Voucher Report (Attachment QI-IO) with the following items:

a. DistrictlUnit/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 State WIC Office Quality Improvement Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the vouchers are subsequently paid by Bank South, they will be identified on the Bank Exception Report during the monthly reporting process.

3. The State WIC Office cannot initiate "stop payments" on lost/stolen or destroyed vouchers. In instances where there are blocks of vouchers either lost/stolen or destroyed from the clinic, local agency Vendor Coordinators should notifY area retail food vendors, provide them with the serial numbers, and inform them not to accept these vouchers for redemption.

4. Document the serial numbers of the vouchers that have been lost, stolen, or destroyed on the Computer Voucher Register or Manual Voucher Inventory.

5.

-if) Complete the Request for Investigation Form (Attachment QI with

the following items:

a. DistrictlUnit

b. Current Date

c. Reason for investigation (is fraud suspected, etc.)

d. List voucher numbers

e. Issue Date

f.

Clinic number

6. Mail the completed Request for Investigation Form to the State WIC Office, Quality Improvement Unit, along with the Lost/Stolen/Destroyed/Voided Voucher Report. The State WIC Office, Quality Improvement Unit, will update the Local Agencies quarterly on these reports, and immediately on reports which indicate suspected clinical fraud.

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GA WIC PROCEDURES MANUAL FY '96

7. Upon receipt of quarterly follow-up reports, the Local Agency should review the reports/vouchers, and if further investigation is required, contact the Quality Improvement Unit within thirty (30) days of receipt.

B. Vouchers Destroyed, Lost By, or Stolen From Participants

When a participant/parent/guardian/caretaker reports that their vouchers have been lost, stolen, or destroyed, the following procedure must be implemented:

I. When a participant reports vouchers as lost, stolen, or destroyed, replacement is at the local agency's discretion. If a local agency elects to replace lost/stolen/destroyed vouchers, steps must be taken to ensure that the policy is implemented consistently in all clinics and with all participants.

Ifvouchers are stolen, the participant must bring a copy of the police report to clinic prior to being issued replacement vouchers. If vouchers are destroyed, any pieces ofvouchers that can be salvaged should be brought to clinic.

When issuing replacement vouchers, the food package must be prorated. The replacement of vouchers must be documented in the participant's health record.

An individual's vouchers may not be replaced more than one (I) time in an issuance period.

2. Complete the l,ost/Stolen Destroyed Voided Voucher Report (Attachment QI-~) 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

f

Participant's WIC ID Number

g. Participant's Status Code

h. 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

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GA WIC PROCEDURES MANUAL FY '96
lost/stolen/destroyed, include all ofthe voucher serial numbers on the form. Note in the comments section of the Lost/Stolen Destroyed Voided Voucher Report that 1-4 vouchers may have been cashed.
3. Mail the completed Lost/StolenlDestroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the State WIC Office Quality Improvement Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the vouchers are subsequently paid by Bank South, they will be identified on the Bank Exception Report during the monthly reporting process.
4. The State WIC Office cannot initiate "stop payments" on lost/stolen! destroyed vouchers. The State Agency, in communication with the Local Agency, will determine if a participant is abusing the Program.
5. When the Local Agency receives the follow-up report/vouchers from the State WIC Office, Quality Improvement Unit, they should review the report/vouchers and determine if fraud is suspected. When fraud is suspected, the Quality Improvement Unit should be notified within thirty (30) days from receipt of the report vouchers.
XI. VOUCHER ISSUANCE SECURITY
A. WIC Vouchers
WIC vouchers are food instruments which mean vouchers, checks, coupons or other documents which are used by a participant to obtain supplemental foods. The State and local agency has the responsibility to maintain control and provide accountability for the receipt and issuance of supplemental foods and food instruments. The state and local agency must also ensure that there is secure transportation and storage of unissued food instruments.
WIC vouchers are negotiable items which are presented to the bank as a check for cash for reimbursement. Therefore all vouchers must be securely protected as checks or cash in order to help prevent voucher theft, and deter program fraud.
I. 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 sign off
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GA WIC PROCEDURES MANUAL FY '96
before leaving the work station;
3. When more than one person is using the same terminal, each person must log offupon completion of their printing job;
4. Pass words must be changed at a minimum, twice a year;
5. When a voucher issuance employee departs their services, change pass words; change security door keys; change location of security keys.
6. Only authorized persons may be given access to WIC vouchers.
7. Computer printed WIC vouchers must be stored separately from the corresponding voucher registers.
B. During issuance, as at all times, WIC vouchers must not be accessible to participants or other authorized persons. Except for the vouchers being issued to the participant you are serving, multiple vouchers must never be placed on top of the issuance space. One of the following methods must be used to assure minimum security of voucher issuance station.
I. 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 ofthe participants, or there must be a physical barrier between the vouchers and the participant;
C. VOUCHER STORAGE
At a minimum, districts must meet one of the following voucher storage procedures when clinics are closed:
I. Ifvouchers 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;
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GA WIC PROCEDURES MANUAL FY '96 5. Vault in a locked building.
D. TRANSPORTING WIC VOUCHERS I. Transporting ofWIC vouchers, voucher register, program stamp, VOC cards, to a clinic site, must be secured in a locked box or briefcase. (see Attachment FD-9)
iil ItBi&. .';IIIi.Bimliiii_mi'ii.i
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GA WIC PROCEDURES MANUAL FY '96 CLOSEOUT RECONCILIATION REPORT

Attachment QI-I

. PAGE 2063'1

STATE OF GEORGIfl IHC SYSTEH

REPORT E~RR840G

CLOSEOUT RECONCILIATION REPORT

GRADY MATL g IHFAHT CARE FOR THE CLOSEOUT HOHTH OF JUNE 1995

VOUCHER REFEREHCE NUMBER HUMBER 25709399 55236263 26'188328 48629635 26'18832'9 26'188330 '18629615 26'1&8331 '18629626 25709404 63771576 25709'105 63771588 2~709406 63771592 2t709'107 63771629 c~709'112 6377162'1 2~J09'113 63771617 :5709414 63771570 ~S709'115 63771616 25709420 52185535 25709421 52185541 25709422 52185557 25709423 52185542 26488336 63851/83 26488337 67212S99 26'188338 63851787 26'188339 67213000 26'1883'1'1 67212970 26488345 42701052 264883'16 63778323 264883'17 67212998 26488352 63851800 26'188353 63851~99 25709428 63867366 25709429 63867371 '25709'130 63867382 257~9'131 6385757'1 2S'i8e356 '12501104 26'158357 68637805 26'188358 '12502548 26488359 68637825 26'18836'1 '12501097 26488365 68637806 26488366 '12502547 26488367 68637820 25709'136 6382711'1 25709437 63827113 25709438 63771610 25709439 '18827778 26'188380 26'188381 26488382

WIC 10

PARTICIPAHT HAME

fAMILY C P

LAST

FIRST

99905'1588 2 1 HARRIS

MAROUIS

697012089 2 1 HAWKIHS

AHTOHIO

697012089 2 1 HAWKIHS

AHTOHIO

697012089 2 1 HAWKINS

ANTONIO

697012089 2 1 HAWKIHS

AHTONIO

699126861 3 1 HAWKIHS

AHTRIHA

699126861 3 1 HflWKIHS

AHTRIHA

699126861 3 1 HAWKIHS

AHTRIHA

699126861 3 1 HAWKIHS

AHTRIHA

9990'13937 5 1 HAWKIHS

CHAZ

9990'13937 5 1 HAWKIHS

CHAZ

999043937 5 1 HAWKIHS

CHAZ

999043937 5 1 HAWKINS

CHAZ

697010260 1 1 HAWKIHS

CHRISTOPHER

697010260 1 1 HAWKIHS

CHRISTOPHER

697010260 1 1 HAWKIHS

CHRISTOPHER

697010260 1 1 HAWKIHS

CHRISTOPHER

697008~23 7 1 HAWKINS

DEAHGELO

697008023 7 1 HAWKIHS

OEAHGELO

697008023 7 1 HAWKIHS

DEAHGELO

6970u3C23 7 1 HA~KIHS

DEAHGELO

699148954 0 1 HflWKIHS

DEHETRIUS

699148954 0 1 HAWKiHS

DEHETRIUS

699148954 0 1 HAWKIHS

DEMETRIUS

699148954 0 1 HAWKIHS

DEMETRIUS

695100454 5 1 HAWKIHS

DERRICK

695100454 5 1 HAWKIHS

DERRICK

697004511 5 1 HAWKIHS

JAHAL

697004511 5 1 HAWKIHS

JAMAL

697004511 5 1 HAWKIHS

J~MAl

697004511 5 1 HAWKIHS

JAMAL

99S051530 7 1 HAWKIHS

JEREMY

999051530 7 1 HAWKIHS

JEREMY

999051530 7 1 HAWKIHS

JEREMY

999051530 7 1 HAWKIHS

JEREMY

697009847 8 1 HAWKIHS

JESSICA

97009847 8 1 HAWKIHS

JESSICA

697009847 8 1 HAWKIHS

JESSICA

697009847 8 1 HAWKIHS

JESSICA

999047451 3 1 HAWKIHS

KIERR~

999047451 3 1 HAWKIHS

KIERRA

999047451 3 1 HAWKIHS

KIERRA

999047451 3 1 HAWKIHS

KIERRA

697005800 1 2 HAWKIHS

KIMBERLY

697005800 1 2 HAWKIHS

KIMBERLY

697005800 1 2 HAWKIHS

KIHBERLY

CLI HI C PAGE 9 O/U/CL 12-0-999 RUH DATE 07/1~/95

VCHR REOMD DATE STATUS

TYPE AHT ISSUED DATE C~HTS

055 10.61 0'1/06/95 05/10/95

0'17 12.14 0'1/14/95 04/18/95

039 .00 04/14/95

EXP

025 9.82 04/14/95 04/18/95

039 6.33 04/14/95 04/18/95

028 8.20 0'1/06/95 04/10/95

031 8.92 0<1/06/95 0<1/10/95

037 14.54 04/06/95 04/1~/95

054 12.26 04/06/95 04/10/95

047 12.14 0<1/06/95 04/10/95

039 6.33 0<1/06'/95 04/10/95

025 9.82 04/06/95 04/10/95

039 6.33 04/06/95 04/10/95

047 12.22 04/12/95 04/19/95

039 6.13 04/12/95 04/19/95

025 10.37 04/12/95 04/19/95

039 6.13 04/12/95 04/19/95

031 8.92 04/11/95 04/13/95

037 13.71 04/11/95 05/01/95

039 6.33 04/11/95 04/13/95

055 9.10 04/11/95 05/01/95

028 7.18 04/05/95 05/01/95

031, 7.23 04/06/95 05/26/95

037 14.54 0'1/06/95 04/10/95

05<1 8.37 0'1/06/95 05/01/95

068 58.87 04/11/95 04/13/95

072 51.40 04/11/95 04/13/95

031 8.92 04/11/95 ~4/13/95

037 14.54 04/11/95 04/13/95

039 6.33 04/11/95 04/13/95

055 9.91 04/11/95 04/13/95

031 8.92 04/11/95 C5/12/95

037 14.54 ~4/11/95 05/05/95

039 6.33 04/11/95 05/12/95

055 9.91 04/11/95 05/05/95

031 8.92 04/10/95 05/12/95

037 14.54 04/10/95 05/05/95

039 ~.33 04/10/95 05/12/95

055 9.91 04/10/95 05/05/95

031 6.87 04/06/95 04/10/95

037 6.95 04/06/9~ 04/10/95

039 6.33 04/06/SS 04/10/95

055 8.53 04/06/95 04/06/95

023 .00 04/0'1/95 04/30/95VOID

031 .00 04/04/95 0'i/30/95VDIO

05'1 .00 0'1/04/95 04/30/95VOID

TOTAL VOUCHERS CASHED T07AL VOUCHERS EXPIRED TOTRL UHHATCHEO TO CERT RECORDS TOTAL VOUCHERS ISSUED VOIDEO UHCUdHE!: TOTAL VOUCHERS CREATEO

CLIHIC TOTALS

VOUCHERS

AHOUH,

805

11,199.66

73

o

.00

878

11,199.66

135

o

1,013

11,199.66

<TOTAL OF CASHED AHD EXPIRED> (COHPUTER AHD HAHUAL VOUCHERS>

QI-16

GA WIC PROCEDURES MANUAL FY '96

OUALITY IMPROVEMENT VOUCHER INVESTIGATION LOG

DIST/UN IT: REASON FOR INVESTIGATION:

DATE:

Attachment QI-2
_ _

VOUCHER ISSUE CLINIC

NUMBER DATE

#

COMPLETED BY:

_ DATE:

_

form 3789 (1-93)

Routing - White Copy- StateWiC Office. Yellow -local Agency

QI - 17

GA WIC PROCEDURES MANUAL FY '96 PARTICIPANT SAMPLE WARNING LETTER

Attachment QI-3

Dear Participant,

It has come to my attention that you have sold food that you get with your WIC vouchers. This is against WIC Program regulations.

The WIC foods are to be eaten by your child so that he can become healthy. The food must be given to him/her and not sold to anyone.

If you continue to sell your WIe food after this warning, your child may be taken off of the WIC Program for up to three (3) months.

If you have any questions, please call me at

'

Sincerely,

WIC Program Coordinator

QI - 18

GA WIC PROCEDURES MANUAL FY '96 REQUEST FOR INVESTIGATION FORM

Attachment QI-4

~of .......... Re-..ces
WIC REQUEST FOR INVESTIGATION

e. DATi:'.

2. NAME AND OFFICE OF OFFICIAL TO WHOM FORM SUBMmED 3. NAME OF PERSON SUBMITTING FORM
{/NCl.UDE DISTRICT}

TO:

FROM:

4. NAME AND ADDRESS OF STORE (INCl.UDE STRECT. CITY. STATE 5. TYPE OF STORE OR FIRM
AND COUNTY)

6. VENDOR .NUMBER

7. NAME OF OWNER OR MANAGER

8. ETHNIC MAKEUP OF STORE'S CLIENTELE

9. HAS STORE BEEN PREVIOUSLV INVESTIGATED?

VesD NoD

10. ARE THERE OTHER STORES UNDER THE SAME OWNERSHIP WHICH ARE AUTHORIZED FOR PART'CIPAT'ON? VesD NoD
If Vn. fill in their Nmes end eddress.

11. TYPES OF ABUSES FOR WHICH INVESTIGATION IS REOUESTED.

.

12. OTHER INFORMATION USEFUL TO THE INVESTIGATOR I1'ROVIDE ADDITIONA.L SHEETS IF NECESSARY}

:-

ROUTING - _ Q>py S,.,., WlC OHa. y.,l_ Q>py - Lo<l A.~
QI-19

GA WIC PROCEDURES lVIANUAL FY '96 WIC TRANSACTION REPORT

Attachment QI-5

VOtJOfERNUM&n
1"

~ D...._ " ' e I

""'"

DiwWoftelPullllc......., .

WlC""" WlCTRANSAcnON REPORT(WTlU

WTIIUTVtUIIDTOWICAGlNCY:

VENDOIt NUMBER

1. ..

. ~ eI WlC

r_ Dape~ ef "-aot

....... tIM

w-Ing

" . . ,. . . . . . . . . . . . . ,

thatthls--..m-ay

In . . . . . . . . .

2. 0II(deta)

.etabout )

thelUllfact_ .laladadthe

..,.cIfiad .......

AtthechacloOUt.-rthaN(wn/MfeI~lnlMahNctel_ _~s)1nIna

_the .......lIIted ......et.tatIl_elClf awalI8bIa)S~

_

-. Theclattr:taldto

. . . .theWICfood~1MIcnacI...... Thepriclaelthe l&HtW_-ud on the leatn(s)...halflndlcaead balow. Iluriftg chacl-.the -.char_In p&aIn" elthe cladl who...,.., - . . .1MM ....... _,.tcM -.tied. the pricIa _ wotIW 101

a. 1'lIMI-.cIStore

_

Approachada-kout

_

Laftstore

_

4. QlfC!:UST
...........ecIonfood(s).. Shalf aa-dadl'rlceonVoucMr 5.COMMIIfTS:

Y.. 110
00 00

Y. . 110

Ups.ala

0 0 Ad.q...t.su"".,elWlCfoodsonShalf

ItIflcaIlonClmlOoedlecl 0 0 GawIlecialpt"' .....aIgetor

y.. lIo
00
o0 _

1.SIX 12.llAa

Ia.AGf

7. OTKla IDINlFtlNG ICfOIlMATlON

..

I 4.HflGKT

l5.wtlGKT

I. tcMl CO\.Olt
I. IDINTlflfD OUItING TaAHSACTlON AS
~I)
1t'lU.MUl_lO_

EUGiBLE ITEMS _ _ _ _OU_A_NTlTY

.
I SUMMARY OF PURCHASE
IlIA_"_O_"_A_M_f

MAN~ Of tDNT1ftCATlON

m_M

PltICE _

INEUGIB~~~
:-

_ J 7 7 J p....t )

IafPUSKTATlVI SIGNAtual

IDATI

QI - 20

GA WIC PROCEDURES MANUAL FY '96

Attachment QI-6

VERIFICATION FORM DISQUALIFIED VENDOR HARDSHIP TO WIC PARTICIPANT

GEORGIA WIC PROGRAM
VERIFICATION FORM DISQUALIFIED VENDOR HARDSHIP TO WIC PARTICIPANT

;:fitre~~it~Q)oc~DTnW_ Ust WIC Vendors Located Near Disqualified Vendor. Vendor Name Address (streetIHWY) DIstance In mUes (only) Vendor Name Address (StreeUHWY) Distance In miles (only) Vendor Name Address (StreeUHWY) Distance In miles (only) Ust WIC vendors within ten (10) miles of Health Department in this area: Vendor Name Address (street/Hwy) Distance In miles (only) Vendor Name Address (StreeUHwy) Distance In miles (only) Vendor Name Address (StreellHWY) Distance In miles (only) RecommendaUons:
Local Agency Signature
QI - 21

GA WIC PROCEDURES MANUAL FY '96
GEORGIA WIC PROGRAM VENDOR DONATION

Attachment QI-7

GEORGIA W.I.C. PROGRAM VENDOR DONATION LIST

MILK

GALLONS

CANS

CEREAL
CHEERIOS CHEX,CORN CHEX.RICE CHEX.WHEAT COUNTRY CORN FLAKES CRISPY CRITTERS HARVEST INSTANT OATMEAL PLUS OAT BRAN JIM DANDY QUICK GRITS IIRON fORTIFIED) KIX MINUTE 3 BRAND INSTANT OATMEAL NABISCO CREAM Of WHEAT (REGULAR FLAVOR) PRODUCT 19 QUAKER INSTANT GRITS (REGULAR fLAVOR) QUAKER INSTANT OATMEALIREGULAR fLAVOR) TOTAL. CORN TOTAL. WHEAT KELLOGGS CORN fLAKES SPECIAL K HARVEST INSTANT OATMEAL PLUS BRAN liM DANDYQUICK GRITS NABISCO CREAM Of WHEAT

OUNCES

CONTRACTED fORMULA

QUANTITY QUANTITY

JUICES APPLE GRAPE GRAPEFRUIT ORANGE PINEAPPLE OTHER

BRAND NAME

FROZEN QUANTITY

CANQUANTI~

DRIED BEANS/PEAS

BRAND NAME

OZ.

QUANTITY

PEANUT BUTTER

BRAND NAME

OZ.

QUANTITY

EGGS

QUANTITY

CHEESE

OZ.

AMERICAN

CHEDDAR

COLBY

MONTEREY JACK

MOZZARELLA

QUANTITY
:-

W.I.C. Representative Date
3790 (Rev. 4-9S)

INSTANT CEREAL OZ. BEECHNUT GERBER HEINZ

QUANTITY

TUNA CARROT

BRANDNAME BRAND NAME

Organization Name

Address

City

_

Organization Representative

Date

PLEASE USE INK

OZ.

QUANTITY

OZ.

QUANTITY

Telephone

_

_

Zip Code

_

_ _

QI - 22

GA WIC PROCEDURES MANUAL FY '96
LOST/STOLENfDESTROYED VOIDED VOUCHER REPORT

Attachment QI-8

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

"
LOSTISTOLEWDESTROYEO' VOIDED VOUCHER REPORT

DISTRICTIUNITlClINIC:

DATE:

INSTRUCTIONS

USE THIS FORM TO REPORT VOUCHERS (COMPUTER OR

MANUAL) WHICH HAVE BEEN LOST. STOLEN. OR DESTROYED BY

EITHER THE PARTICIPANT OR THE eUNlc.

SUBMIT AT LEAST MONTHLY.

MAIL TO:

VIKING COMPUTING. INC.

GEORGIA WlC UNIT

P.O. BOX 2504

GREENWOOD. IN 461422504

STATUS CODES
LOSTISTOlENlDESTROYED .2 VOIDED. 3

BEGINNING VOUCHER NO.

ENDING VOUCHER NO.

OUANTITY

Wle I.D.NUMBER

STATUS
CODE

COMMENTS

- ~

-

I

I

I

'~~n

TOTAL VOUCHERS !1~

~II

QI- 23

GA WIC PROCEDURES MANUAL FY '96

Attachment QI-9

NOTIFICATION SUMMARY OF MISSING VOUCHERSNOC CARDS

GEORGIA WIC PROGRAM

NOTIFICATION SUMMARY OF MISSING VOUCHERSNOC CARDS

II

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)

IMMEOIATELY'/notifv suoervisor' WIC/Coordinator' and the Police.

Complete the following information:

(All SECTIONS MUST BE COMPLETED)

(Section I) Name ofperson who discovered the vouchersNOC cards missing.

D/U/C_ _ _

Name of person completing this form. if different from above

(section III Name of person(s). who is responsible for vouchersNoc cards at this clinic.

(Section III)

Number of Missing Voucher

Number of Missing VOC Cards

note: a separate form must be completed if both Vouchers and VOC cards are missing

Discovered missing: Date Supervisor notified: Date Coordinator notified: Date

T i m e_ _ _am_ _ _pm

Time

am

pm

Time

am

pm

VOUCHER'S Beginning #

Ending #

VOC CARDS Beginning #

Ending #

(Section IV) Complete a detailed summary of how vouchersNOC cards were descovered missing.

( Use additional sheets of paper if needed. and attach)
(Section V) list any additional information that would apply to this case.

( Use an additional sheets of paper if needed. and attach)

(Section VII Signature of person completing report
(submit completed report to WIC Coordinator/Person in chargel

Person receiving the report:

Title:

Date:

( This signature is to verify receipt of this report, not to verify information on report. I

WlC 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

QI- 24

TABLE OF CONTENTS
I. State Agency Monitoring A. Introduction. B. Monitoring Schedule C. Clinic & Health Record Selection. D. Pre-Review Activities. E. Files F. Timeframes G. On-Site Visit 1. Entrance Conference . 2. Exit Conference H. Written Reports I. Close-Out Report .
II. Quality Assurance Self-Reviews III. Technical Assistance .
Attachments:

.... MO-l

. .... MO-l

.... MO-l

.

MO-2

. .. MO-3

... MO-3

... MO-5

..... MO-5

. MO-~

.... MO-6

.. MO-6

.. MO-7

. .... MO-8

.... MO-9

GA WIC PROCEDURES MANUAL FY'96
I. STATE AGENCY MONITORING
A. Introduction
The State agency will conduct an on-site monitoring visit every two (2) years to all nineteen (19) public health district WIC programs and two (2) contracted WIC agencies for the purpose ofreviewing local agency operation. The districts/agencies which are not monitored for the year will receive priority for on-site technical assistance. The purpose ofthis visit is to ensure local agency compliance with State and Federal WIC regulations. The review will consist of an evaluation of program administration, voucher issuance, certification, food package assignment, and nutrition education.
In order for the above areas to be thoroughly evaluated, it is necessary for the-m'onitoring team to observe at least one (1) clinic in full operation. A minimum of three (3) certifications/subsequent certifications must be observed. Ifthe monitoring team is unable to make these observations, they must reschedule that part of the review. The review cannot be closed until the clinic observations have been completed.
The on-site visit will be made by a monitoring team from the State WIC Office and the Office of Nutrition. Every effort will be made to conduct all portions (Programmatic, Financial, Vendor, QI, Systems, and Nutrition) ofthe review during the same time period.
B. Monitoring Schedule
A schedule of on-site monitoring visits will be developed and coordinated by the State WIC Office and the Office of Nutrition, prior to the start of each Federal Fiscal Year (FFY). A statewide schedule containing the dates and monitoring teams for each review will be sent to all local agencies.
Each district must submit a master clinic schedule to the Office of Nutrition two (2) months prior to their scheduled review. The WIC Coordinator will be notified by phone, approximately one (1) month prior to the review, ofthe specific clinics (randomly selected and staff selected) to be monitored. A letter will then be sent to the WIC Coordinator and the District Health Officer to confirm the clinic selection, the dates of the review, the time and place for the entrance and exit conferences, etc. Additional information that will be requested for the review (by the State) will be included in the letter sent to the WIC Coordinator.
MO-l

GA WIC PROCEDURES MANUAL FY'96

C. Clinic and Health Record Selection

1. Clinic Site

Every two (2) years, twenty percent (20%) of the total number of clinics in the state are randomly selected for program monitoring evaluation. The following limitations have been imposed on the random selection:

a Clinics that were monitored during the previous two program review cycles will not be included in the random selection.

b. Each local agency may have a maximum of five (5) clinics selected for review. If

more than five (5) clinics are randomly selected, those in excess will be eliminated

from the selection.

-~

c. The largest clinic in each local agency will be monitored during each program review. If it is not randomly selected, it will be added to the list of clinics to be reviewed within a local agency. Ifa maximum of five (5) clinics have already been chosen, the largest clinic in the District will replace the last clinic on the random selection list of clinics to be reviewed.

Within each local agency, at least twenty percent (20%) of the clinics or two (2) clinics, whichever is greater (with the exception of Southside Healthcare, Inc.), will be monitored during the on-site review. Once the randomly selected clinics are grouped according to districts, additional clinics may be selected by the State in order to ensure that the minimum requirement is met.

2. Record Selection

Health records monitored during the program reviews will be randomly selected. The following constraints will be applied to the random selection:

a. Two (2) records will be randomly selected for each 100 participants enrolled in a clinic, up to one thousand participants. If a clinic has more than one thousand participants, an additional two (2) records will be selected for each five hundred (500) participants above one thousand. Note: a minimum of six (6) records will be reviewed in each clinic.

b. Fifty percent (50%) ofthe records selected must be women's records. The remaining fifty percent (50%) will include infants and children. Note: If a record selected for review cannot be located in the clinic during the review process~ the Local Agency will be cited for a corrective action.

MO-2

GA WIC PROCEDURES MANUAL FY'96
3. Migrant Health Records
The State must review migrant health records during a local agency program monitoring visit. Migrant health records will be selected in local agencies where there is a significant number of migrants in the service area.
a. Where there is at least one clinic site with a minimum of twenty-five (25) migrants participating in the WIC Program, records are randomly selected according to the above procedures in 2a.
b. If a clinic site serving a significant number of migrants is not selected for program reviews, migrant health records will be selected and reviewed according to the procedures in 2a.
c. Ifa significant number of migrant population is in a local agency service area and is not participating in the WIC Program, the state must evaluate the local agencies outreach efforts related to migrants.
D. Pre-Review Activities
Prior to the on-site visit, State staffwill review local agency reports and files in the State office. The WIC Coordinator will be contacted about materials that need to be made available during the on-site review.
E. Files
Documentation and files to be considered during an on-site review include, but are not limited to, the following areas:
I. Past Program Review Reports and Responses 2. Quality Assurance Self-Reviews 3. System Maintenance Indicator Report 4. Food Cost Projection Report 5. Ethnic Enrollment Participation Report 6. Clinic Schedules 7. Outreach Activities 8. Waiting List(s) 9. GA WIC Program Procedures Manual 10. WIC Policy Memorandums
MO-3

GA WIC PROCEDURES MANUAL FY'96
II. Georgia WIC User Manual 12. Federal WIC Regulations 13. Fair Hearing and Civil Rights Complaints 14. Participant Abuse Reports 15. Manual Voucher Inventories 16. VOC Cards and Inventory 17. Batch Control Modules 18. Completed Computer Voucher Registers 19. Voucher Packing Lists 20. Lost/Stolen Voucher Reports 21. Copies of Manual Vouchers 22. Ineligibility Files 23. District Specific Policies and Procedures 24. WIC Resource Referral Booklet 25. Multi Service Application 26. Local Agency Nutrition Education Plan 27. Nutrition Education Materials 28. Lesson Plans 29. Training Files 30. Financial Management Files:
General Ledger (current and previous year) General Joumal (current and previous year) Check Register (current and previous year) Certified Payroll (current and previous year) Time Study (current, if possible) Bank Reconciliations (current and previous year) Back-up Documentation for Line Item Expenditures (e.g. travel, regular
operating expenses, etc.) Competitive Bids Documentation (one [1] month) Single Audit Report (current year, if possible) Equipment Inventory (current year) Chart of Accounts 31. Voter's Registration Files
MO-4

GA WIC PROCEDURES MANUAL FY'96

F. Timeframes

The program review process will be conducted within the following timeframes:

ACTIVITY

TIMEFRAME

1. Notifications of intent to conduct a review-SWOIOON contact Local Agency to discuss possible review dates

30 days prior to the scheduled date

2. SWOIOON prepares and submits a report of program observation and review to Local Agency

within 30 days of the exit interviews

3. Locat Agency submits response to program review to SWOIOON

within 45 days ofthe date of program review report

4. SWOIOON submits written response to the Local Agency review

within 15 days ofthe date Local Agency response

5. Local Agency submits written response to SWO request for additional information

within 15 days of the date of the written request

6. Program review closed G. On-Site Visit

within 140 days of the exit interview

During the on-site visit, the local agency will make accessible all reports, forms, and files requested. Local agency staffwill be asked to respond to questions asked by State staff. Staff must be available to answer questions during the clinic visit. The average review for a district will take from three (3) to five (5) days.

1. Entrance Conference

An optional entrance conference can be scheduled to officially begin the review. The

MO-5

GA WIC PROCEDURES MANUAL FY'96
District Health Director, Program Manager, WIC Coordinator, and any other pertinent staff are invited to participate in the entrance conference. During this conference district staff will have the opportunity to provide an overview of their district and ask questions of the State monitoring team.
State staffwill:
a. Make introductions; b. Explain the purpose of the visit; c. Review the district specific monitoring schedule; and, d. Briefly explain what will take place during the review. e. Discuss pertinent district specific information/data.
2. Exit Conference
An optional exit conference with clinic staff can be held in each clinic monitored to review the specific clinic findings.
Upon completion of the on-site district review, the monitoring team will meet privately to prepare for the exit conference. They will then meet with the District Health Director, Program Manager, WIC Coordinator, and other local agency staff as designated by the District Health Director. The following will be discussed at this conference:
a. Areas deserving commendation; b. Achievements; c. Corrective actions (NOTE: Clinics and records are randomly selected,
therefore all corrective actions apply districtwide); and d. Recommendations
H. Written Reports
The State will send a written report of the review to the District Health Director within thirty (30) days of the exit conference. The report will address areas of special achievement, recommendations, and corrective actions. The district will respond to all corrective actions within forty-five (45) days from the date ofthe State agency report.
A written plan of action must be developed for all program deficiencies identified during the program review. The action plan must be districtwide and address each corrective action. Addressing recommendations in the plan is optional. The plan must ensure that the questions Who?, What?, When?, Where?, and lIow? are addressed. For example: who will be trained, what will the training be on, when will they be trained,
MO-6

GA WIC PROCEDURES MANUAL FY'96 where will the training be held, and how will the training be conducted.

NOTE: All training mnst be performed within sixty (60) days from the date on the Program Review Report.

All supporting documentation must be included in this plan. Examples of supporting documentation include:

1. An agenda and dates of training and a list of staff that have attended the training.

2. A copy of all the memorandums sent out to local agency staff by the WIC Coordinator addressing problems found during the program review.

3. Copies of information that could not be located during the on-site monito'ring visit that relate to specific corrective actions.

4. Iftraining is not conducted to close a review, the WIC Coordinator has the options to send copies of procedwes in the Procedures Manual out to each Local Agency. Ifthis option is chosen, the only acceptable documentation the State WIC Office will accept to close the review will be the signatures of staff indicating that they have read and understood the procedures.

The review will not be closed until all planned training have been conducted.

Once the State agency has received the local agency response to the written report, it may elect to do one or more of the following, based on the action plan:

I. Close the review. 2. Request additional information. This information will be due fifteen (15) days from
the date of the request. 3. Make a follow-up monitoring visit within six (6) months ofthe exit conference. 4. Offer technical assistance to help develop a corrective action plan or train local
agency staff.

The local agency will receive written notification of the above, from the State agency, within fifteen (15) days from the receipt of the action plan.

1.

Close-Out Report

A written close-out report will be sent to the Local Agency upon the satisfactory

MO-7

GA WIC PROCEDURES MANUAL FY'96
resolution of all corrective actions. The close-out report is written documentation that the corrective action plan has been accepted ani! the program review is closed. All program reviews must be closed within 140 days of the exit interview.
II. QUALITY ASSURANCE SELF-REVIEWS
Purpose
The purpose of self-evaluation is to improve the quality of Local Agency program operations. Internal self-evaluations allow local agencies to assess compliance of program operations with WIC policies and procedures. Early identification and resolution of non-compliance improves the quality and strengthens the operations of the local agency.
Non-compliance to WIC Program policy and procedures is considered a deficiency in Program Management and Operation. Through self-reviews the Local Agency can identify deficiencies and take immediate action to correct non-compliance, prior to the program review conducted by the state.
Self Reviews
The Local Agency must conduct an internal self-review annually. The assessment will include all phases ofthe program operations. The State WIC Office "Local Agency Monitoring Tool" is utilized to evaluate operations of each clinic in the district. In instances where the Local Agency has developed an evaluation tool.
Local agency internal review must include at a minimum:
Caseload trends System Maintenance Indicator Reports Non-participation evaluation Service Integration and Clinic Flow Outreach and referrals Processing Standards Certification procedures Chart Audit Accountability offood instrument and issuance materials'Nutrition Services Financial Records & Expenditures Civil Rights Compliance Participant Complaints Fair Hearing
MO-8

GA WIC PROCEDURES MANUAL FY'96 At the time of the Local Agency program review, the State review team will review all documentation pertaining to the self-reviews. In the event that all self-reviews are not completed, the local agency must provide to the review team a plan and a schedule for completing the self-review. USDA recommends that a nutritionist be a member of the Local Agency Quality-Assurance team conducting self-reviews. Non-compliance with the internal self-review procedure constitutes a deficiency in the local agencies program operations. Like all other program deficiency, an action plan must be developed to correct the deficiency.
ID. TECHNICAL ASSISTANCE Technical assistance will be provided by the State agency to all local agencies on an on-going basis. On-site technical assistance will be provided when requested by the locai agency. Technical assistance may also be provided to the local agency through telephone contact or correspondence with the State agency. On-site assistance provided to local agencies will be documented on a Technical Assistance Report form. A copy ofthisreport will be placed in the District's file and a copy will be sent to the District WIC Coordinator.
MO-9

GA WIC PROCEDURES MANUAL FY'96

Attachment MO-l

STATE OF GEORGIA Department of Human Resources
Division of Public Health State WIe Office Office of Nutrition
LOCAL AGENCY MONITORING TOOL
FFY '96

MO-IO

I I I I I I I I I I I I I I I I I I I I

GA WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

PURPOSE: Federal Regulations require state agencies to establish procedures for reviewing local program operations. The "Local Agency Monitoring Tool" was designed as the instrument to be used in completing this review.
GENERAL INSTRUCTIONS: Local agencies are encouraged to use this tool as a guide in preparing for the State agency review. Monitoring efforts will ensure compliance as well as emphasize quality assurance. The format of the monitoring tool has been designed to enable local agency responses to be recorded in a narrative form.
SPECIFIC INSTRUCTIONS: The monitoring tool is divided into seven (7) parts as follows:
I. Administration Section Local Program Management Clinic Operation Clinic Observation Chart Review
II. Civil Rights Administration Training Complaint Handling
III. Food Instrument Accountability
IV. Systems Management
v. Vendor Management
VI. Financial Management
VII. Certification and Nutrition Services CertificationlNutrition Education (Office ofNutrition) Clinic Observation: Individual Nutrition Education Session Clinic Observation: Group Nutrition Education Session Clinic Observation: Questions for Clinic Staff Anthropometric Equipment Hematologic Equipment Clinic Observation Anthropometric Measurements Record Review

LOCAL AGENCY MONITORING

A.RT I ADMINISTRATION

Name of DistrictlLocal Agency:

_

Address:

_

WIC Coordinator:

Telephone #

_

Clinic(s) to be Reviewed: (Attach a copy of lb. District Clinic Listing)

Clinic #

Clinic Name

Clinic #

Clinic Name

Clinic #

Clinic Name

Clinic #

Clinic Name

Clinic #

Clinic Name

Review Schedule

Entrance Conference:

Date:

_ Time

Place:

_

Exit Conference:

Date:

_ Time:___ Place:

_

2

LAST REVIEW CORRECTION PLAN

~ad last annual program review and corrective actions. Were planned corrective actions taken? Are the same ficiencies still occurring (answer after current review)?

Last Review Deficiency

Training Needed

Same Deficiency Identified This Year

Yes No

Yes

No

).
l.
~.
3. 3

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

'ART I ADMINISTRATIVE SECTION

Guidelines

Areas of Review

Recommendation

I.

Program Management (District Office)

A.

Is an organizational chart available for review?

(Attach a copy)

Yes No NA

Comments
-

Corrective Action

B.

Policy and Procedures

l.

Does the District Office have a copy of all

Policy Memorandums on file?

Corrective Action

2.

Is a copy of the Procedures Manual

located at the District Office?

Recommendation

C.

System Maintenance Indicators

-~

l.

Are System Maintenance Indicators in

compliance with State Standards?

(Review these reports prior to an on site

monitoring/self-review visit(s). *In the

event a Districtllocal agencies non-

participation rate is 10% or above a

technical assistance and/or a plan must be

submitted to the State WIC Office.

20rrective Action

2.

Is at least 55% of prenatal caseload

emolled in the first trimester?

20rrective Action

D.

Caseload Management (must have approval from

state)

l.

Has the District implemented a waiting

list since the last review?

20rrective Action

2.

Is there a current waiting list? If yes,

what Priorities are being served?

20rrective Action Recommendation

E.

Internal Communication

*l.

Are new policies and State Memos sent to

staff?

Are staffmeetings held regularly?

Date of the last meeting:

*Coordinator use for Integrated Clinic * *Coordinator/Staff Use for Integrated Clinic

2.

Is there a planned method of

communication between WIC staffand

non-WIC staff? (i.e. Staff Meetings)

4

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
~ecornmendation
:::orrective Action
:orrective Action

Areas of Review

Yes No NA

*3.

Is in-service training conducted regularly

for WIC and non-WIC staff providing

WIC services?

Comments

Date of the last meeting:

-

F.

Fair HearingslParticipant Complaints (Review

District files prior to monitoring Review)

l.

Is there documentation for Fair Hearings

and action taken on File? Is it available

for review at the District and State Office?

2.

Were they handled/resolved according to

program procedures?

If no, please explain:

-,

:orrective Action

G.

Quality Assurance SelfReview

l.

Does the District conduct internal

monitoring? (Review the Monitoring

File)

(Attach a copy of the Review Schedule)

2.

Is there a list of deficiencies identified for

each clinic?

(ecornmendation ~orrective Action

3.

Was there a corrective action plan written

for each clinic?

4.

Does the Agency use the State Monitoring

Tool?

5.

Are the following program indicators

included in the local assessment?

(District)

SMI Reports Caseload Trends Non-Participation Waiting List Service Integration and Patient Flow Outreach an Referral Trimester of Enrollment

6.

Have any special initiative efforts been

implemented as the result of internal

..

monitoring?

5

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
Recommendation
Corrective Action Corrective Action Recommendation

Areas of Review

H.

Outreach

Yes No NA

l.

Does the District have a plan for

developing and conducting outreach

activity pertinent to the local service area?

If yes, are outreach activities documented and available for review?

Ifno, explain how WIC information is disseminated to applicants/participants and local communities.

2.

Has the district or local clinic conducted

outreach activities within the last 12

months?

Are all outreach activities documented and available for review? (See Outreach File)

*3.

Has any special outreach activities been

initiated to reach high risk persons in

priority I, II, and III?

If yes, please describe and provide documentation.

Ifno, how does the District ensure that high risk persons are informed about WIC services?

Comments
-

Corrective Action

4.

Are high risk participants contacted prior

to termination for non-participation?

Ifyes, please describe how the contact is made?

Ifno, please explain. (Review documentation)

6

A WIC PROCEDURES MANUAL FY'96

;uidelines
:orrective Action

Areas of Review

5.

Have special provisions been made for

scheduling the following applicants?

Explain:

Employed Participants

Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

-

Rural Participants Clinic
-~

Clinic

Migrants

:orrective Action
:orrective Action :orrective Action :orrective Action

6.

Are grass roots organizations, minority

group and other agencies serving

potentially eligible WIC clients informed

ofWIC eligibility requirements and

significant program changes?

Ifyes, is a listing of these groups and organizations on file in the clinic? (Review documentation)

1.

Referral Section

1.

Are WIC outreach materials sent tot he

referral agencies? (District)

J.

Processing Standards

1.

Has the District requested an extension

for Processing standard?

If yes, is the written approval of extension on file and available for review?

K.

Civil Rights Training

1.

Is Civil Rights training conducted

a=ually for local WIC staff? (District)

When

By Whom

7

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
:orrective Action :orrective Action :orrective Action :orrective Action :orrective Action
:orrective Action Corrective Action Recommendation Recommendation

Areas of Review

Yes No NA

2.

Is Civil Rights training included in new

employee orientation? (Review List of

new employees and Documentation of

Civil Rights Training) (District)

3.

Civil Rights complaints are handled in

accordance with established program

procedures. (Review Complaint File -

Number ofComplaints)

L.

Public Notification/Public Hearings

1.

Has the District conducted Public

Hearings? Review the Public Hearing

File concerning the date(s) oflast

hearings and locations.

2.

Was a summary of the Hearings sent to

the State WIC Office?

M.

Public Notification

1.

Has the general public been notified of

WIC Program information with regards to

non~iscrimination policy within the last

12 months? (District)

Ifyes, is there documentation ofhow it was done?

If no, please explain:

II.

Clinic Review

*A. Caseload Management

1.

Does the clinic have a waiting list?

*2.

Are proper procedures followed when

maintaining a waiting list?

3.

Describe procedures for activating a

waiting list.

*B.

Coordination and Integration

1.

Are WIC services coordinated or

integrated with other health department

services?

*2.

Are WIC appointments coordinated:

Clinic

Comments
-
-~

8

;A WIC PROCEDURES MANUAL FY'96

Guidelines
Recommendation Recommendation

Areas of Review

*3.

How is this coordinated?

*4.

Are WIC participant medical records

integrated with other records?

Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

-

Recommendation

*5.

Ifkept separate, why?

Clinic

Reason

--

-~

--

--

Recommendation

--

--

*6.

Does clinic staff request or check

immunization records when WIC services

are provided?

Clinic

Recommendation

*7.

Does clinic flow appear to be smooth?

Clinic

9

;A WIC PROCEDURES MANUAL FY'96

Guidelines
Recommendation

Areas of Review

C.

Complaints

l.

Has the local agency received any

complaints since the last review?

(Review Staff local agency files).

Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

-

Recommendation

2.

Review StatelLocal Agency Files. How

many?

Clinic
-c

Recommendation

3.

Were the complaints resolved?

Clinic

Corrective Action

D.

Referrals

*l.

Does the staff assess the need to refer

participants to other services (i.e.

medicaid, food stamps, AFDC, child

health, immunizations, headstart, etc.?

Clinic

Corrective Action

*2.

Does the local clinic maintain a referral

list of other agencies, offices, or

programs?

If yes, review documentation

Clinic

.. -

10

A WIC PROCEDURES MANUAL FY'96

:;'uidelines
~ecommendation

Areas of Review

*3.

Ifno, what method is used to refer

applicants/participants to other needed

services?

Clinic

Attachment MO-I (cont'd)

Yes No NA

Comments

-

~ecommendation

E.

Processing Standards

**l. Does the local agency utilize an

appointment system for scheduling

applicants/participants appointments?

Clinic

-~

0-

~ecommendation

**2. Clinic

Are no-shows and cancellations taken in account when scheduling WIC appointments and other clinic activities?

~ecommendation

**3. If no, how are clients scheduled for WIC services?
Clinic

11

A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

;uidelines
;orrective Action

Areas of Review

Yes No NA

**4. Are initial contact dates documented and available for review?

Clinic

Comments
-

When an applicant misses an appointment who reschedules the appointment?
Clinic
-~

~orrective Action

**5.
Clinic .
Clinic Clinic Clinic Clinic

What is the next available appointment for an applicant requesting WIC benefits? (See appointment book)

Women(p) Women(B) Woman(pP)

Infant Child

Women(p) Women(B) Woman(pP)

Infant Child

Women(P) Women(B) Woman(pP)

Infant Child

Women(p) Women(B) Woman(pP)

Infant Child

Women(p) Women(B) Woman(pP)

Infant Child

12

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
Corrective Action

Areas of Review
**6. What are the processing standards time frames for: (Ask Staff)

Time Frames

Clinic(l)

Prenatal Postpartum Infants Children Migrants

Clinic(2)

Prenatal Postpartum Infants Children Migrants

Clinic(3)

Prenatal

Postpartum

Infants

c

Children

Migrants

Clinic(4)

Prenatal Postpartum Infants Children Migrants

Clinic(5)

Prenatal Postpartum Infants Children Migrants

Yes No NA

Comments
-
-c

Corrective Action

7.

Is the clinic meeting processing standard?

(See documentation)

13

;A WIC PROCEDURES MANUAL FY'96

Guidelines
Corrective Action

Areas of Review

F.

Income Assessment

1.

Is income taken before the certification

process or after the certification?

Clinic

Attachment MO-1 (cont'd)

Yes No NA

Comments

-

Corrective Action

2.

"What is the defmition of "family"?

Clinic

-:

Corrective Action

**3. Does the clinic determine an applicant to be income eligible based on presumptive eligibility requirements? Where is it documented?
Oinic

Corrective Action

4.

Are there certain situations when an

applicant's income must be verified?

Clinic

Ifyes, what are the situations? Clinic

Corrective Action

G.

Certification Process

1.

Are there instances when you must verify

an applicant/participant's identification?

14

A WIC PROCEDURES MANUAL FY'96

:;'uidelines

Areas of Review
Ifyes, please explain. Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

-

~orrective Action

2.

What forms of participant identification

do you accept?

Clinic

~

~orrective Action

3. Clinic

Is the local staffknowledgeable ofproper procedures for notifying applicants and participants of their eligibility or ineligibility? (Staff interview and review Ineligible file) (Use Attachment 1)..
..

~orrective Action

4.

Are participants notified that their "WIC

certification is about to expire prior to

expiration of their certification period?

Clinic

::orrective Action

5.

How are they notified and is the

notification documented?

Clinic

15

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
Corrective Action

Areas of Review

Yes No NA

6.

Are persons who are tenninated during a

valid certification period notified prior to

termination?

Clinic

Comments
-

Corrective Action

7.

Certification Periods

Is the staff knowledgeable of certification periods? (Staff interviews)

Time Frames Time Periods

-~

Clinic

Women(p) Women(BF) Woman(pP)

Infant Child

Clinic

Women(p) Women(BF) Woman(pP)

Infant Child

Clinic

Women(p)

Infant

Women(BF)

Child

~

Woman(pP)

Clinic

Women(p) Women(BF) Woman(pP)

Infant Child

Corrective Action

Clinic 8.

Women(p) Women(BF) Woman(pP)

Infant Child

Does the clinic provide WIC benefit only during a valid certification period?

(Select a sample of records with the message "RECERT OVERDUE M11DDYY" to whom vouchers were issued to review compliance, use Attachment 2.)

16

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
:orrective Action

Areas of Review

9.

Does the clinic allow a proxy to bring a

child in for recertification or to pick up

vouchers?

Clinic

Yes No NA

Comments
-

Jfyes, describe the circumstances. Clinic

:orrective Action

10.

Does the local clinic have a system for

transfers? (Complete Transfer of

Certification Work Sheet Attachment 3)
.

Clinic

:orrective Action

11.

Are VOC cards issued and accepted by

the local clinic to verifY WIC

certification?

Clinic

:orrective Action :orrective Action

12.

Are the VOC card records accurate and

monitored according to program policy?

(Complete VOC Monitoring Work Sheet)

Attachments 4 A and B

13.

Are VOC cards stored in a locked place

separate from the inventory log?

Clinic

17

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
Corrective Action

Areas of Review

Yes No NA

14.

Is the inventory of VOC cards conducted

monthly according to program

procedures? (Review physical inventory

ofVOC Card Log)

Clinic

Comments
-

Corrective Action

15.

Are two signatures of Local Agency Staff

on VOC Card Inventory monthly?

Corrective Action

16.

Is a VOC Card Poster displayed in each

clinic?

--

Corrective Action

H.

Special Population (Migrant)

1.

Does the local agency caseload include

migrants?

Ifyes, is the staffknowledgeable of procedures for handling migrants?

Clinic

Income VOCCards

Clinic

Income VOCCards

Clinic

Income VOCCards

Clinic

Income VOCCards

Clinic

Income VOCCards

18

A WIC PROCEDURES MANUAL FY'96

Guidelines
::orrective Action

Areas of Review

1.

Voter Registration

1.

Is each participant issued a Voter

Registration FOnTI?

Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

-

~ecommendation

2.

Where are Voter Registration FOnTIS and

Files kept? Are they kept in a locked

location?

Clinic
-~

::orrective Action

J.

Smoking

1.

Are No Smoking signs posted in the

clinic?

Clinic

Ifno, why not:

::orrective Action ::orrective Action

II.

CIVIL RIGHTS

A.

Administration

1.

Are WIC services provided in non-

discriminatory manner?

3.

Are facilities where WIC services are

provided accessible to physically impaired

persons without hardship? (Observation)

Clinic

19

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
Corrective Action

Areas of Review

Yes No NA

4.

Do facilities which are not accessible to

physically impaired persons have written

procedures for alternative arrangements to

provide WIC services? (Review

documentation)

Clinic

Comments
-

Corrective Action

5.

Does the clinic serve non-English

speaking applicants/participants?

Clinic

-:

Corrective Action

6.

Are interpreters or bilingual staff

available for the non-English speaking

clients, if applicable?

Clinic

Ifno, explain how WIC information is communicated to them.
Clinic

Corrective Action

7.

Is the local agency in compliance with

program policy regarding racial or ethical

coding and filing of participants records?

(Review Clinic Medical Records)

Clinic

20

~A WIC PROCEDURES MANUAL FY'96

Guidelines
:orrective Action

Areas of Review

C.

Complaint Handling

1.

Is staffknowledgeable of proper

procedures for handling Civil Rights

complaints?

Clinic

Attachment MO-I (cont'd)

Yes No NA

Comments

-

:orrective Action

2. Clinic

Are participants informed of Civil Rights complaint procedures?

-~

:orrective Action

E.

Compliance

1.

All persons have equal opportunity in the

WIC Program regardless of race color,

national origin, age, sex, or handicap?

Clinic

:orrective Action

2.

Does Local Agency comply with

program policy ofdetermining

participants raciaVethnicity?

Clinic

:orrective Action

III. Issuance Materials

1.

Are vouchers mailed?

Clinic

21

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
Corrective Action

Areas of Review

Yes No NA

2.

Are the following items stored in a secure

location:

l.

Program Stamp

2.

VOC Cards

Clinic

Comments
-

Corrective Action

IV.

Record Review

(See Attachment 5) Copy additional sheets

Corrective Action

V.

Clinic Observation

-:

Corrective Action

(See Attachment 6)

VI.

Equipment Inventory

(See Attachment 7)

:

22

A WIC PROCEDURES MANUAL FY'96

ATTACHMENT 1

INELIGffiLE CERTIFICAnON WORK SHEET

eview three (3) records in each clinic of individuals found ineligible at the time of certification and/or of Idividuals who were terminated from the Program within the last year.

istrict,

_

Clinic

Name

Reason for Ineligibility or Termination

Was Notice of Fair Hearing
Given?

Signature & Date of Person Determining Eligibility Complete?

--

23

A WIC PROCEDURES MANUAL FY'96

ATTACHMENT 2

elect a random sample of at least three (3) records for which the following message "RECERT OVDUE IMDDYY' appears and to whom vouchers were issued. It is important that six-week postpartum women be in Ie sample.

istrict

_

Clinic

Participant Name

Month of Report

Status WIC

Delivery Date

Issue Date

Pick Up Date

Were Vouchers
Validly Issued?

-,

lote: This information is pulled from the Voucher Register. 24

~A WIC PROCEDURES MANUAL FY'96

ATTACHMENT 3

TRANSFER OF CERTIFICATION WORK SHEET

\lhat is the District policy for accepting transfers?

Clinic:

VOCCARD

CALL TRANSFERRING CLINIC

WRITE FOR RELEASE OF

- ..

MEDICAL INFORMATION

ASSESS AS AN APPLICANT

ASSESS AS AN APPLICANT & WRITE FOR TRANSFERRING INFORMATION

GIVE ASSESSMENT APPOINTMENT

GAI.D.CARD

CERTIFICATION RECORD

OTHER:

25

;A WIC PROCEDURES MANUAL FY'96

,umbers for VOC Cards issued to the District from the State:

WMBERS

DATE ISSUED

TO

TO

DATE ISSUED

TO

TO

Ire VOC card inventories current and accurately kept:

At the District level? Yes___ No

_

>ISTRICT

CARD #'S ISSUED

ATTACHMENT 4-A
DATE ISSUED TO
DATE ISSUED TO
DATE ISSUED

At the clinic level? :LINIC

Yes_ _ _ No- - -

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

26

CARD NUMBERS

~A WIC PROCEDURES MANUAL FY'96 VOC CARD SECURITY REPORT
'ull five (5) records in each clinic from the VOC Card Log.

ATTACHMENT 4-B

Participant's Name

Date Issued

Signature of Parent/Guardian/Caretaker

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Signatures Match
Yes No Yes No Yes No Yes No Yes No - c Yes No Yes No Yes No Yes No Yes No Yes No Yes_NoYes_NoYes_NoYes No Yes_ NoYes_No_ Yes- NoYes_No_ Yes No Yes No Yes No Yes No

Dates from TAD Match
Yes_NoYes No Yes No Yes No Yes No Yes No Yes No Yes No_ Yes No Yes NoYes_NoYes_NoYes_No_ Yes_No_ Yes_NoYes_No_ Yes_No_ Yes_NoYes_No_ Yes No Yes No Yes NoYes No

27

;A WIC PROCEDURES MANUAL FY'96

ATTACHMENT 5

RECORD REVIEW

~eview the following criteria in the records randomly selected by the Office of Nutrition:

PARTICIPANT NAME

:LINIC,

_

CRITERIA TO REVIEW:
Initial Contact Date
Categorically Eligible?
Signatureffitle ofPerson Collecting IncomelResidence Data
Participant's SignaturelDate
Medicaid Eligibility Documented
Medicaid Number
Food Stamps YIN?
Number in Family?
Income Information Documented
Income Eligible?

,

~ote: Make copies of this form for Record Review.

28

;A WIC PROCEDURES MANUAL FY'96 CLINIC OBSERVATION

ATTACHMENT 6

ENVIRONMENT

1.

Handicap Ramp

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

4.

Were clinic participants waiting

for long periods of time?

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

7.

Are participants treated with

courtesy?

Clinic

Yes No

--

-

-

-

-

-

-

-

-

2.

"And Justice For AlI Poster"

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

3.

Is clinic flow efficient?

Clinic

Yes No

-

-

-

-

-

-

-

-

-, -

-

5.

Does the clinic have comfortable

waiting areas offering privacy for

health screening and counseling?

Clinic

Yes No

6. Clinic

Does the reviewer observe any practices that could be considered discriminating?
.
Yes No

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

8.

Is the VOC Card displayed in the

clinic?

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

B.

CERTIFICATION (INCOME)

1.

Determined prior to nutritional

risk assessment

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

29

;A WIC PROCEDURES MANUAL FYt 96

ATTACHMENT 6 (CONT'D)

a. Clinic

MedicaidIFood Stamp Verification Yes No

-

-

-

-

-

-

-

-

-

-

b. Clinic

Are these accepted as income eligibility?
Yes No

-

-

--

-

-

-

-

-

-

c.

Presumptive eligibility?

Clinic

Yes No

--

-

-

-

-

-

-

-

-

d.

Required to show proof of income

at certification?

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

e.

Explain any exceptions observed.

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

2,

Verification of identification

What proof of I.D. was asked for at certification?

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

3.

Were participants informed of the b.

VOCCard

following:

Clinic

a.

Rights and Obligations

Clinic

Yes No

-

-

-

-

-

-

-

-

-

-

Yes No

-

-

-

-

-

-

-

-

-

-

c.

How to use I.D. Card

Clinic

Yes No

-

-

-

-

-

-

--

-

-

30

~A WIC PROCEDURES MANUAL FY'96

1.

Is the facility accessible to

handicapped participants?

Clinic

Yes No

ATTACHMENT 6 (CONT'D)

31

;A WIC PROCEDURES MANUAL FY'96

ATTACHMENT 7

EQUIPMENT INVENTORY

Vas the equipment inventory sent in by October 1 ofthe new fiscal year?

Yes

_ No

_

:an all the equipment be located?

Clinic (Write in name)

Equipment Number

Located

Yes

No

Yes- - No

Yes

No

Yes

No- -

Yes

No- -

Yes

No

Yes- -
Yes

No- No

Yes

No

Yes

No

Yes- - No

Yes

No

Yes

No

Yes- -
Yes

No- No

Yes

No

Yes

No

Comment
.

32

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

ART ill Guidelines

FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Areas of Review

Yes No NA

A.

Packing List

Comments

Is a copy of the packing list received by the District within two days of clinic verification?

B.

Voucher Issuance

l.

Does the Local Agency have a policy for

issuing vouchers to eligible WIC

employees and their family members?

2.

Are any local agency staff receiving WIC

benefits at the clinic site where they

work?

3.

Are any family members ofWIC staff

-~

receiving benefits at local clinic where the

staff is employed?

4.

Are staff members at the clinic allowed

to issue vouchers or process certification

for family members?

C.

Participant Abuse

1.

Has the District received any reports of

participant's abuse since the last Program

Review?

2.

Was the report investigated?

3.

Was the report sent to the State WIC

Office?

D.

Dual Participation

l.

Have there been any cases of intentional

dual participation since the last

monitoring review?

2.

Was the report sent to the State WIC

Office?

E.

Missing Vouchers

l.

Have the District Office received notice of

missing vouchers from the WIC clinics

since the last Program Review?

2.

Was the report investigated?

3.

Was the report sent to the State WIC

Office?

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

III. Food Instrument Accountability (Clinical Review)

A.

Manual Voucher Inventory Log

Yes No NA

1.

Is the Log being completed on all

vouchers?

Clinic Clinic Clinic Clinic Clinic

2.

Is the Manual Voucher Log complete and

accurate?

Clinic Clinic Clinic Clinic Clinic

B.

P,?rpetual Inventory

1.

Is perpetual inventory done on all manual

vouchers?

Clinic Clinic Clinic Clinic Clinic

2.

Is perpetual inventory complete and

accurate?

Clinic Clinic Clinic Clinic Clinic

3.

Is inventory done weekly?

Clinic Clinic Clinic Clinic Clinic

Comments

34

A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

;'uidelines

Areas of Review

C.

Manual Voucher Physical Inventory

Yes No NA

Comments

1.

Are any vouchers missing?

Clinic Clinic Clinic Clinic Clinic

2.

Does physical inventory match the

inventory log?

Clinic

Clinic

Clinic

-~

Clinic

Clinic

3.

Is physical inventory conducted monthly?

Clinic Clinic Clinic Clinic Clinic

4.

Is physical inventory done on all manual

vouchers?

Clinic Clinic Clinic Clinic Clinic

D.

Manual Voucher Copies

I.

Are vouchers filed by serial number

order?

Clinic Clinic Clinic Clinic Clinic

2.

Are any vouchers missing or misfiled?

Clinic Clinic Clinic Clinic Clinic

35

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

Yes No NA

3.

Are vouchers kept in binder or folder?

Comments

Clinic Clinic Clinic Clinic Clinic

4.

Have any vouchers been altered with

writeovers or scratch outs?

Clinic

Clinic

Clinic

Clinic

Clinic

- .-

E.

Reconciled Packing List

1.

Is the Packing List verified, signed, and

dated?

Clinic Clinic Clinic Clinic Clinic

2.

Are vouchers accurately recorded on the

Manual Inventory Log?

Clinic Clinic Clinic Clinic Clinic

3.

Are copies of packing list sent to the

District Office?

Clinic Clinic Clinic Clinic Clinic

36

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

F.

Voucher Register Documentation

Yes No NA

Comments

1.

Are there any blank lines on the Voucher

Register?

Clinic Clinic Clinic Clinic Clinic

2.

Is clerk's initials missing?

Clinic

Clinic

Clinic

-,

Clinic

Clinic

3.

Are any dates missing?

Clinic Clinic qinic Clinic Clinic

4.

Are any participant's signatures missing?

Clinic Clinic Clinic Clinic Clinic

5.

Does Voucher Register contain required

closeout signatures and dates? '

Clinic Clinic Clinic Clinic Clinic

G.

Voucher Security

1.
Clinic Clinic Clinic Clinic Clinic

During office hours, are vouchers securely . stored or in possession of authorized staff?

37

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

Yes No NA

2.

Are vouchers secured during staff lunch

breaks?

Clinic Clinic Clinic Clinic Clinic

3.

Are vouchers properly secured overnight?

Clinic Clinic Clinic Clinic Clinic

4.

Are vouchers stored apart from the

voucher register?

Clinic Clinic Clinic Clinic Clinic

5.

Are vouchers securely stored separate

from ID cards?

Clinic Clinic Clinic Clinic Clinic

6.

Are WIC ID cards stored separate from

the Program Stamp?

Clinic Clinic Clinic Clinic Clinic

H.

Voucher Issuance

1.

Does the Voucher Register show

documentation of prorating vouchers?

Clinic Clinic Clinic Clinic Clinic

Comments -:

38

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

2.

Is prorating consistent?

Yes No NA

Clinic Clinic Clinic Clinic Clinic

3.

Are unissued prorated vouchers stamped

void at the time of issuance?

Clinic Clinic Clinic Clinic Clinic

4.

Is staff knowledgeable of the proper

procedures for prorating?

Clinic Clinic Clinic CJinic Clinic

5.

Are voided vouchers stored according to

procedures until forwarded to the ADP

contractor?

Clinic Clinic Clinic Clinic Clinic

6.

Are vouchers transported from one site to

another?

Clinic Clinic Clinic Clinic Clinic

7.

When vouchers are transported, are they

in a locked container (lockbox, briefcase)?

Clinic Clinic Clinic Clinic Clinic

Comments
~

39

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

1.

Local Agency Policies

Yes No NA

Commemts

l.

Does the local agency have a policy for

issuing vouchers to employees/family

members?

..

Clinic

Clinic

Clinic

Clinic

Clinic

2.

Are any staff in this clinic receiving WIC

benefits at this location?

Clinic Clinic

-~

Clinic

Clinic

Clinic

3.

Are any staff family members receiving

WIC benefits at this location?

Clinic

Clinic

Clinic

,

Clinic

Clinic

4.

Are clinic staff allowed to issue vouchers

or certify family members?

Clinic Clinic Clinic Clinic Clinic

1.

Participant Abuse

1.

Has the clinic had any problems with

participant's abuse since the last program

review?

Clinic Clinic Clinic Clinic Clinic

40

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

2.

Was the coordinator notified?

Yes No NA

Clinic Clinic Clinic Clinic Clinic

3.

To your knowledge was there an

investigation conducted?

Clinic Clinic Clinic Clinic Clinic

D.

Dual Participation

l.

Has the clinic followed up on each dual

participation case received at the clinic?

Clinic CJinic Clinic Clinic Clinic

2.

Are findings documented?

Clinic Clinic Clinic Clinic Clinic

3.

Have there been any cases of intentional

dual participation since the last

monitoring visit?

Clinic Clinic Clinic Clinic Clinic

Comments
.-
.

41

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

K.

Missing Vouchers

Yes No NA

1.

Have any vouchers been missing during

the last twelve months?

Clinic Clinic Clinic Clinic Clinic

2.

Was a Lost, Stolen, Destroyed voucher

Report sent to the State WIC Office?

Clinic Clinic Clinic Clinic Clinic

3.

Was supervisor/coordinator notified ofthe

missing vouchers?

Clinic Clinic Clinic Clinic Clinic

'ARTIV SYSTEMS INFORMATION UNIT

Guidelines

Areas of Review

1.

General Infonnation

Reviewer:

Date:

Yes No NA

Comments
.-c
Comments

1.

DistricUUnit:

2.

Clinic Number:

3.

Clinic Name/Address:

4.

Contact Person:

5.

Telephone: ( )

42

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

6.

GIST:

II.

District Infonnation

Yes No NA
'.

1.

Type of Systems Used:

ATVS

MVS

M&M

DIU System

2.

Number of Computers Used for WIC

3.

Number of Clinic Staff authorized to use

the System:

4.

Number of Clinic Staff listed as

Supervisors:

5,

Request a list of authorized users for each

of the computers to be inspected.

6.

Are any non-elinic staff authorized to use

the computer(s) (i.e. District WIC Office

Staff or State Staff?) If yes, are those

persons listed at the District Office as

well?

7.

Request a copy of the District's

standardized 99 series vouchers.

8.

Do any clinics have series 99 vouchers on

its computer(s) that are not included on

other computers in the District?

III.

Physical Security

1.

Are computers, printers and vouchers

located in an area that is not readily

accessible to participants.

If no, does the clinic have room to reposition the equipment in order to protect it from unauthorized persons?

2.

Is the computer locked in a secure (a) area

when the clinic is closed or (b) when non-

WIC activities are taking place?

Comments -~

43

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

Yes No NA

3.

Are blank vouchers that are not currently

loaded into the printer stored in a secure,

locked area?

IV. Voucher Accountability

1.

Are all vouchers entered into the

computer immediately upon receipt?

2.

If the clinic uses more than one computer,

are vouchers divided among them and

entered upon receipt?

3.

If voucher stock is divided into smaller

batches, are the batches entered into the

computer individually?

4.

Ifvoucher stock is divided into smaller

batches, is each batch clearly labeled to

indicate which computer and in what

order the vouchers are to be used?

5.

Is voucher stock sequence number in

agreement with the computer inventory?

6.

Are files maintained for voucher copies?

7.

Are third copy (black) vouchers destroyed

in such a manner as to protect the identity

ofWIC participants?

V.

Program Security

1.

Is the system backed up twice daily?

2.

Is a separate set of diskettes used for the

A.M. and P.M.?

3.

Is each set of diskettes clearly marked

A.M. and P.M.?

4.

Are back-up diskettes replaced after three

months?

5.

Are users deleted from the system as soon

as they are transferred, terminated or

otherwise leave the WIC Program?

6.

Is a list ofusers and their passwords kept

in the Clinic?

7.

Do users routinely log out ofthe system

each time they are done writing TADS

and/or vouchers or ifthey will be away

from the computer?

Comments
..
-~
..

44

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

Yes No NA

8.

Do the clinic WIC Staff run the

incomplete record report to catch up on

those records at least weekly?

9.

Are all files re-indexed at least once per

week?

10.

Does the clinic maintain a supply of pre-

numbered paper TADS for use in

emergencies?

I!.

Does the clinic maintain a supply of blank

manual vouchers for use in emergencies?

12.

Does the clinic maintain a supply of

paper TADs, both Pre-Numbered (if

applicable) and blank for use in

emergencies?

13.

Does the clinic maintain a supply of blank

standard vouchers for all WIC types as

well as blank manual (99 series) vouchers

for use in emergencies?

14.

Does the clinic computer list of series 99

vouchers confirm with the District Office

list?

If no, is there a reason for discrepancies such as special cases which have been approved by the District Office?

15.

After backing up (internally) does the

computer list any vouchers for which

there is no client masterfile? (Only

allowable exceptions are voided vouchers

with "VOIDED FNAl\t1E" entries).

16.

In the VOUCHER MESSAGEIMAX

PRICES table "are the not to exceed

prices" current?

17.

Do the backup diskettes contain all ofthe

following files?

BACKUP.ZIP PKUNZIP.EXE PKZIP.EXE

18.

Does the file creation date on both backup

diskettes indicate that backups are being

done daily and at the proper times?

19.

Are acknowledgement dates for TAD and

Voucher Patches posted?

Comments
- .-

45

GA WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

Yes No NA

20.

Is this ATVS version in use this current

release?

Comments

PART V

VENDOR MANAGEMENT

Guidelines

Areas of Review

Yes No NA

A.

Does the local Agency maintain individual vendor

files to include all correspondence and reports

pertaining to each specific vendor?

1.

Does the Local Agency ensure that its

method of documentation and

maintenance ofvendor information is

accurate and effectively meets the needs

of the Local Agency and State Agency?

2.

Does the Local Agency's vendor files

include the Post Vendor Training

Evaluation and the Sanction Point System

forms?

B.

During the Vendor Application Process, did the

Local Agency Representative visit the stores and

complete the Vendor Review Forms (Attachment

VN-16).

1.

Are Vendor Applications and the Vendor

Review Forms submitted to the State

WIC Office by the end of the first month

of each quarter (January 31, April 30, July

31, October 31)?

C.

After the approval of each vendor, did the Local

Agency issue one vendor stamp to the Y::.I.l4.9r and
1i.~'II~ir:~~~a~~'9~s;::~!~~anual

(as evidenced by a completed Vendor Input!

Registration Form)?

D.

Has the Local Agency replaced any lost or

damaged vendor stamps?

1.

If a replacement or additional stamp was

issued to a vendor, was the State WIC

Office notified?

2.

If yes, what means of documentation was

submitted to the State WIC Office?

E.

If a vendor was terminated, were the vendor stamps

returned to the State WIC Office with a copy of the

Vendor InputlRegistration Form within 30 days?

Comments -~

46

A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

Yes No NA

Comments

l.

If the stamp was not retrievable, was a

Vendor InputlRegistration Form

submitted to the State WIC Office with a

statement noting the reason why the

stamp was not returned?

F.

Has a Vendor Agreement (Attachment VN-4) been

signed between the Local Agency and the new

vendor?

l.

Was a new Vendor Agreement signed by

October 1 of each Federal Fiscal year in

order for a vendor to be authorized to

accept WIC vouchers?

2.

If no, did the Local Agency retrievethe

vendor stamp from any vendor that did

-:

not sign an agreement by October I of the

new Federal Fiscal year?

G.

Did the Local Agency submit a copy of the Vendor

Agreement to the State WIC Office within thirty

(30) days from the date the contract was signed?

1:

Were Vendor Agreements to renew

current vendors received by the State WIC

Office no later than November I of each

Federal Fiscal year?

2.

If no, explain the reason for the delay.

H.

Did the Local Agency complete the Vendor

Training Information Form after the [mal training

session in the DistrictlUnit?

l.

Does the Local Agency allow the

vendor(s) a grace period often (10)

working days, prior to September 30 of

the fiscal year, to attend the District! Unit

make-up training session?

1.

What percentage of a district's vendors were

visited during the past two Federal Fiscal years?

l.

Has the Local Agency made a monitoring

visit of all the vendors in their district at

least once every two (2) years?

2.

Did the Local Agency monitoring

representative complete each section of

the Review Tool when each Vendor was

monitored?

47

~A WIC PROCEDURES MANUAL FYt 96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

Yes No NA

J.

Did the Local Agency revisit any stores within sixty

(60) days if violations were found during

monitoring visit to see if the violations have been

corrected (excluding New Vendor Review visits)?

K.

Does the Local Agency assist the State with the

investigation of all vendors identified as high risk

due to administrative violations of possible abuse?

Comments

ART VI FINANCIAL MANAGEMENT

Guidelines

Areas of Review

A

WIC Program Rderences and Manuals

Yes No NA

I.

Do the employees have a copy of the

following manuals?

a.

Georgia WIC Procedures

Manual

b.

USDA FNS Instruction 808-1

c.

Otv'lB Circulates A-87 and A-

102

d.

Georgia DHR Grants-To-

Counties Policy and procedures

Manual, Parts lILE, Attachment

1 and 1X.A,B

B.

Review of Previous Audit Findings

1.

Has an audit been performed recently by

an independent accounting firm?

2.

Were any fmdings noted? (Ifyes, attach a

copy of the audit containing these

findings.)

3.

Were measures taken in response to these

findings?

c.

Budgets

1.

Are the appropriate WIC budgets and

revisions for the current fiscal year

available for review?

2.

Are budget revisions submitted and

approved if expenditures for a line item

exceeds ten percent (10%) above the

budgeted amount?

Comments - .-

48

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

Yes No NA

3.

Are budgets revised and submitted in a

timely manner when allocations are

made?

4.

Are copies of contracts attached?

D.

Expenditures

Comments

l.

Are expenditure reports submitted in a

timely manner?

2.

Are expenditures for nutrition education

monitored to ensure expenditure levels are

a minimum of one-sixth (116) of total

administrative expenditures?

E.

Generally Accepted Accounting Practices

l.

Are accounting records maintained by

WIC paid staff or by the district

accounting personnel?

2.

Does the local agency maintain a separate

account for WIC funds?

- .-

I

If not, is adequate documentation maintained to identify revenues and disbursements for the WIC Program?

3.

Are revenues for the WIC Program

deposited in an interest bearing account?

4.

Are source documents protected from

damage or unauthorized access?

5.

Does the Local Agency use a

computerized accounting system?

If yes, is the hard drive backed up daily on floppy diskettes?

6.

Are floppy diskettes maintained in the

financial office and protected from

unauthorized access?

7.

Are hard copies of all accounting

transactions printed and maintained for

reference?

8.

Is there a separation of duties for the

various accounting tasks?

49

GA WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines

Areas of Review

Yes No NA

Comments

9.

Is the bank reconciliation performed by an

employee who is independent of cash

disbursements or receipts and general

ledger maintenance?

10.

Is the signing of checks independent from

-

the approval of invoices?

II.

Is the preparation of checks independent

from the approval of invoices?

12.

Are the receiving duties independent of

the purchasing function?

13.

Is there a limitation on the dollar amount

for checks which only require one

signature?

-~

14.

Are invoices and supporting

documentation examined at the time of

signing and marked "paid" to prevent

duplication of payment?

IS.

Are records maintained for the required

length of time? (3 years plus current)

F.

Documentation of Time

I.

Has the District completed a time study as

required?

2.

Is documentation attached to the time

..

study to support and track the amount of

personnel time devoted to WIC services

by: WIC paid and non-WIC paid staff?

G.

Equipment

1.

Are proper equipment inventory records

maintained?

2.

Has a physical inventory been conducted

within the last year?

3.

Do inventory records indicate:

a.

Inventory decal number

b.

Description of equipment

c.

Serial number (ifapplicable)

d.

Location of equipment

e.

Date of purchase

50

~A WIC PROCEDURES MANUAL FY'96

Attachment MO-1 (cont'd)

Guidelines

Areas of Review

Yes No NA

f

Acquisition cost

g.

Percentage ofWIC participation

in the purchase

4.

Has USDA and/or State WIC Office

approval been obtained for equipment

purchases as required?

5.

Are the proper procedures followed to

dispose of obsolete or damaged

equipment?

6.

Are the proper procedures followed when

equipment is discovered, lost or stolen?

H.

Indirect Costs

l.

Does the District charge any indirect costs

to the WIC Program?

If yes, does the local agency have an approved Indirect Cost Allocation Plan on file?

2.

Have cost charged to the WIC program

also been charged to all other programs

for which they benefit?

3.

Has the cost allocation plan been applied

correctly in making reimbursements?

Comments I

ART VII CERTIFICATIONINUTRITION EDUCATION - OFFICE OF NUTRITION

Guidelines

Areas of Review

Yes No NA

Comments

Corrective Action

I.

Food Package Assignment

A.

List title(s) of competent professional authorities

(CPA's who assign food packages for participants:

I

Corrective Action

B.

Is there a protocol for infant food package changes

from the contract formula to the non-contract

formula?

If yes, which of the following do you use:

State Protocol:

Local Agency Policy:

(please provide a copy to the reviewer)

51

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont/d)

Guidelines
Corrective Action
Recommendation Recommendation Recommendation

Areas of Review

Yes No NA

C.

What guidelines are used for food package

tailoring? (please provide reviewer with any

written communications to clinic staff on food

package tailoring.)

D.

What system is used for obtaining and tracking the

use of prescription formulas?

E.

What procedures are used to follow up on infants

who are on special formulas? (please provide a

reviewer with a copy of written procedures.)

II.

Nutrition Education

Comments

A.

Training (1be following questions must be asked

separately ofthe WIClNutrition Coordinator and the Clinical Coordinator.)

-,

1.

At the time of the program review, please

provide the reviewer with a summary of

all nutrition inservices/ training attended

by local staff since the last review.

Recommendation
Recommendation Recommendation Recommendation Recommendation

List provided?

2.

How are district/clinic inservices recorded

for: "

a.

Competent Professional

Authorities?

b.

Paraprofessionals?

c.

Other clinic staff? (please

specifY staff titles)

3.

How are training needs assessed?

4.

How do staff evaluate:

Recommendation

Corrections Action

B.

a.

the training sessions

themselves?

b.

training effectiveness over time?

Paraprofessional Training

Corrective Action

1.

Are paraprofessionals used to certifY

participants?

2.

Are paraprofessional used to provide

secondary nutrition education contacts?

52

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
Corrective Action Corrective Action Corrective Action
Corrective Action
Corrective Action Recommendation

Areas of Review

Yes No NA

3.

Has the training plan for

paraprofessionals been approved by the

Office of Nutrition?

Comments

If yes, the date:

4.

Have all lesson plans for training

paraprofessionals been submitted to the

Office of Nutrition for approval?

If no, please provide reviewer with lesson plans at the time of review.

5.

Has the district submitted, to the Office of

Nutrition, a list of paraprofessional staff

providing secondary nutrition education

-~

contacts?

If yes, date provided: - - -

If no, please provide the reviewer a list at the time of review.

.

C.

Nutrition Education Plan

1.

Was a two-year Nutrition Education Plan

received by the Office of Nutrition by

April I (of appropriate year)?

If yes, date:

If no, date received:

Not Received:

NA if review prior to April I of the appropriate year.

2.

Was an annual progress report received

by the Office ofNutrition by December l?

Ifyes, date: _ _

If no, date received:

Not received: - - -

3.

Give status of each Nutrition Education

Plan objective:

53

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
Corrective Action
Recommendation Recommendation Recommendation
Corrective Action Recommendation Recommendation
Recommendation
Corrective Action
Recommendation Corrective Action

Areas of Review

D.

Participant Nutrition Education Contacts

Yes No NA

Comments

1.

What lesson plans for nutrition education

have been developed since the last

review? Please provide the reviewer with

a copy at the time of review.

-

2.

Describe the system used to provide two

(2) nutrition education contacts for each

six (6) month certification per participant.

3.

What method is used to document

secondary nutrition education contacts?

4.

Since the last program review, has the

system for providing and/or documenting

nutrition education contacts changed?

-~

Ifyes, explain how:

5.

Are missed nutrition education

appointments documented?

Ifyes, describe the method used:

6.

How are the Nutrition Guidelines for

Practice being used?

7.

Have the Nutrition Guidelines for Practice been

used for training since the last review?

Ifyes, explain how and list guidelines used:

If no, discuss reasons:

8.

Is there a method for referring, to a nutritionist,

individuals who are in need of more in-depth

nutrition counseling?

Ifyes, what criteria are used to make referrals?

E.

Nutrition Education Materials

1.

Who approves nutrition education

materials and forms not provided by the

State?

2.

What methodes) is/are used to evaluate

nutrition education materials?

3.

A list of all approved nutrition education

materials and a copy ofthose not

available through Central Supply are to be

provided to the Office of Nutrition. List

provided?

i

54

A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
Corrective Action Corrective Action Recommendation
Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation
Recommendation

Areas of Review

Yes No NA

4.

Are materials provided which meet the

needs of specific population groups~

5.

Are inappropriate nutrition education

materials available for participant's use?

III. Breastfeeding Promotion and Support

This section should be addressed with both the WIC coordinator and the local agency breastfeeding coordinator.

A.

Breastfeeding Coordinator

1.

What are the names and credentials!

qualifications of the breastfeeding

coordinator?

2.

How many hours per week/month does

the breastfeeding coordinator spend on

breastfeeding promotion and support

activities?

3.

Is the breastfeeding coordinator position

permanent or on contract?

4.

Does the breastfeeding coordinator

conduct activities agency-wide or

primarily in one location?

5.

Describe the major responsibilities and

activities of the breastfeeding coordinator:

6.

Does the breastfeeding coordinator

provide individual counseling?

Ifyes, please answer the following:

a.

Where does individual

counseling take place?

- -Clinic
Phone _ _Participant's Home _ _Hospital _ _Other (please specify)

b.

Individual counseling is

provided to:

Prenatal Women Breastfeeding Women

Comments -~

55

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
Recommendation

Areas of Review

c.

How is individual counseling

documented?

Yes No NA

Comments

Recommendation Recommendation

Central File _ _Participant health
record _ _Other (please specif'y)

If in the health record, describe the process for documentation, including the time lag between counseling and documentation:

B.

Encouragement to Breastfeed

1.

How is encouragement to breastfeed

- .-

provided in the prenatal period?

Individual Contact

_ _PrenataIlBreastfeeding Class

_ _Other (please specify):

Recommendation

2.

Describe the process for individual

.

contacts being provided (when, by whom,

documentation):

Recommendation

3.

Describe the process for provision of

prenatal classes to include breastfeeding

(when, by whom, documentation):

Recommendation

C.

Training

1.

Please provide, at the time ofthe review, a

list of:

_ _Training attended by breastfeeding coordinator

Recommendation Recommendation

_ _Training provided by breastfeeding coordinator

2.

Describe how you assure that clinic staff

are knowledgeable about current

breastfeeding issues:

3.

Do you have a referral system for

participants who require more in-depth

counseling or assistance on

breastfeeding?

I

If yes, describe how this is done and who provided the in-depth counseling.

56

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines
Recommendation
Corrective Action Corrective Action Corrective Action Corrective Action

Areas of Review

4.

Other

Yes No NA

Please describe any breastfeeding activities not addressed above (e.g., peer counseling, special projects, media exposure, etc.).
IV. SPECIAL PROJECTS, INITIATIVES, AND ACCOMPLISHMENTS IN THE PROVISION OF NUTRITION SERVICES (OPTIONAL)

A.

What Public Health Nutrition services are available

in your Local Agency?

B.

Describe the special projects, initiatives, and/or

accomplishments in the area of breastfeeding,

nutrition education and nutrition materials being

implemented in the Local Agency:

C.

What requests ofthe DistrictiLocal Agency have of

the Office of Nutrition staff to assist in

implementing Nutrition Education and

Breastfeeding Plans and providing nutrition

s"rvices?

V.

CLINIC OBSERVATION: INDIVIDUAL

NUTRITION EDUCATION SESSION

DATE:

CLINIC:

REVIEWER:

Participant status:

PBNIC

Participant priority:

I II III IV V VI

Participant risk factors:

ABCDEFGHIJKL MNOPQRSTUVW XYZ

Time estimate for total contact:

Time estimate for NE contact:

A.

Nutrition Education

l.

Is diet evaluated according to Georgia

WIC standards (intake, summary, food

practices, evaluation)?

2.

Does NE relate to participant status?

3.

Does NE relate to participant risk factors?

4.

Does NE relate to diet recall/assessment?

Comments

57

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-I (cont'd)

Guidelines

Areas of Review

Yes No NA

Corrective Action

5.

Does NE include WIC foods and their

relationship to participant risk?

Recommendation

6.

Does NE include total food intake and its

relationship to participant risk?

Corrective Action

7.

Does NE follow Nutrition Guidelines for

Practice?

Recommendation

B.

Communication

Comments

l.

Does counselor invite questions?

Recommendation

2.

Does participant ask questions?

Recommendation

3.

Is session conducted in language

participant speaks/understands?

- ,"

Recommendation

C.

Materials (includes posters, flip charts, food

models, pamphlets, etc.)

Corrective Action Corrective Action Recommendation

1.

Are materials in patient's primary

language?

2,

Do materials relate to risk factor?

3.

Do materials relate to counseling session?

D.

Space

1.

Is space private?

Recommendation

2.

Is there seating for counselor?

Recommendation

3.

Is there seating for participant and others

in session?

Recommendation

4.

Is space quiet enough to talk normally?

Recommendation

5.

Is the view of the participant/counselor

obstructed by materials on the desk or by

the seating arrangement?

E.

Additional Comments

58

~A WIC PROCEDURES MANUAL FY'96

Guidelines

Areas of Review
VI. CLINIC OBSERVATION: GROUP NUTRITION EDUCATION SESSION

DATE:

CLINIC:

REVIEWER:

Topic:

Composition of Group (prenatal, breastfeeding mothers, caregivers of infants, etc.):

Attachment MO-I (cont'd)

Yes No NA

Comments

Expected Attendance:

Actual Attendance:

-~

No show rate (calculate percent):

%

Recommendation

Time Estimate for NE Contact:

A.

Integration

1:

Session conducted to connection with:

Recommendation

Certification Voucher Pickup
. Other Appointment
Specify

B.

Nutrition Education

Recommenation Corrective Action Recommendation

l.

Does NE include WIC foods and their

relationship to nutritional status?

2.

Does NE include total food intake and its

relationship to nutritional status?

3.

Does NE follow Nutrition Guidelines for

Practices?

C.

Communication

Recommendation Recommendation Recommendation

l.

Does instructor invite questions?

2.

Do participants ask questions?

3.

Does instructor respond to questions?

D.

Materials!Media

l.

Is session conducted in language(s)

participants speak?

59

~A WIC PROCEDURES MANUAL FYt 96

Attachment MO-l (cont'd)

Guidelines
Recommendation Recommendation
Recommendation Corrective Action
Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation
Recommendation Recommendation

Areas of Review

2.

Are materials/media in language(s)

participants speak?

3.

Media used:

Yes No NA

Film/Filmstrip Slideffape Show Video Tape PosterlFlip Chart Food Models Pamphlets Other Specify:

4.

Are print materials related to information

covered during session?

E.

Staff

Session conducted by:

Nurse Nutritionist P!llaprofessional Other Specify:

F.

Evaluation of Knowledge and Satisfaction

1.

Any evaluation of participant's nutritional

knowledge base?

2.

Any evaluation of knowledge gained in

session?

3.

Any evaluation of participant's attitudes

about nutrition and diet?

4.

Is participant satisfaction evaluated?

Ifyes, how?

G.

Space

1.

How is room arranged?

2.

Where is the session conducted:

Waiting room

Private room

Other

Specify:

3.

Is there seating for participants?

4.

Can participants see instructor?

Comments
.-

60

:;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

Guidelines
Recommendation Recommendation
Recommendation

Areas of Review

Yes No NA

5.

Can participants hear instructor?

6.

Can participants see video, film, or other

visual aids?

7.

Can participants hear any audio aids?

H.

Additional Comments

Comments

VII. CLINIC OBSERVATION: QUESTIONS FOR CLINIC STAFF (Must be completed in at least one (1) clinic)

Date

Clinic

Reviewer

- .-

Staff person interviewed: Nurse

Nutritionist

Paraprofessional

Recommendation

A.

Is the Nutrition Guidelines for Practice used as a

reference?

Recommendation
I Recommendation
! Recommendation
Recommendation

If yes, how/when?

B.

How is breastfeeding encouraged?

C.

Who assigns food packages in the clinic?

D.

How is the food package assignment for a

participant determined?

E.

How is the effectiveness of nutrition education

counseling sessions assessed?

61

;A WIC PROCEDURES MANUAL FY'96

VII. ANTHROPOMETRIC EQUIPMENT

Date

Clinic

--'Reviewer

OBSERVATIONS

S-Satisfactory
U-unsatr.sf:actorv
#1 #2 #3

I. Length Board: a. Moveable foot piece at 90% angle that slides easily

b. Foot piece at a 90% angle

c. Fixed headboard

2. Height Board: a. Fixed measuring device (fixed to vertical flat surface, no skirting)

b. Right angle head board

3. Standing Scales: a. Calibrated in last 12 months (use scale test report or sticker)

b. Beam scale

4. Infant Scale: a. Calibrated in last 12 months (use scale test report or sticker)

b. Beam Scale

Attachment MO-I (cont'd) _
COMMENTS
I
I
-c

62

~A WIC PROCEDURES MANUAL FY'96

{. HEMATOLOGIC EQUIPMENT

Date,

Clinic,

~Reviewer

A Type of equipment used (brand/model) for hgb, or hct

Attachment MO-l (cont'd) _

R Calibration 1, How is equipment calibrated?

2, Who calibrates the equipment?

3, How often is equipment calibrated?

4, How is calibration documented?

C Balancing/Checking Accuracy 1, How is equipment balanced or checked for accuracy?

2, Who balances/checks the equipment?

3, How often is the equipment balanced/checked?

4, How is the balancing/checking of equipment documented?

63

;A WIC PROCEDURES MANUAL FY'96

Attachment MO-l (cont'd)

(. CLINIC OBSERVATION: ANTHROPOMETRIC MEASUREMENTS

Date

Clinic

Reviewer---:---:-

-:--_:------:_ _:-:-

----:----:_ _

Observe at least one (1) standing height, standing weight, recumbent length, and infant scale weight.

Woman/Child (Standing Height)

1.

Participant measured without shoes

2.

Proper stance used for reading measurement

3.

Headboard is level, touches top of head

4.

Correct angle used for measurement

5.

Measurement taken to nearest 1/8 inch

6.

Two (2) measurements taken

Woman/Child (Standing Weight)

1.

Participant dressed in minimal clothing

2.

Scale zeroed, prior to measurement

3.

Correct angle used for reading measurement

4.

Weight measured to nearest 1/4 pound

5.

Two measurements taken

Infant/Child (Recumbent Length)

1.

Participant measured with minimal clothing

2.

Body straight, lined up with measuring board

3.

Head is against headboard throughout measurement

4.

Footboard resting fmnly against heels

5.

Correct angle used for reading measurement

6.

Measurement read to nearest 1/8 inch

7.

Two (2) measurements taken

Infant Child (Infant Scale Weight

1.

Participant dressed in minimal clothing (without wet diaper)

2.

Scale zeroed, prior to measurement

3.

Correct angle used for reading measurement

4.

Weight measured to nearest 1/2 ounce

5.

Two (2) measurements taken

Woman

Status'

AGe'

Yes

No

Child

Yes

No

Yes

No

- .-

Yes

No

Infant

Yes

No

-,. Yes

ChIld No

Yes

No

Yes

No

64

~A WIC PROCEDURES MANUAL FY'96
."I. RECORD REVIEW
RECORD REVIEW District Clinic Date

1.

Participant Status Recorded (Women Only)

2.

Medical Data Date

3.

LengthlHeight Recorded

4.

Weight Recorded

5.

HctlHgb Recorded

6.

Age Recorded

7.

LengthlHeight Plotted

8.

Weight Plotted

9.

Weight for LengthlHeight Plotted

10. Diet Intake Recorded

11.

Diet Sum~ary Completed"

12.

Food Practices Evaluated

13. Diet Evaluation Documented

14.

Date Signature & title (Diet Form)

15.

All Nutritional Risks Checked

16. All Nutritional Risks Documented

17. Priority Correct

,

18. Food Pkg. Assigned

19. Food Pkg. Number

20.

ReferralslEnrollment Documented

21.

Today's Date

22.

Professional's Signatures & titles (Cert. Form)

23.

Primary NE Contact, Current Certification

24.

Secondary NE Contact, Current or Prior Cert.

25. Breastfeeding Encouraged

26.

High Risk Follow-up Documented

65

Attachment MO-I (cont'd)
T 0 T A L

GA WIC PROCEDURES MANUAL FF'96 TABLE OF CONTENTS

I. Introduction

. BF-l

II. Definitions

. BF-l

III. State Agency

. BF-2

A. Breastfeeding Coordinator

. BF-2

B. Breastfeeding Promotion, Education and Support Responsibilities

BF- 2

IV. Local Agency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BF- 4

A. Breastfeeding Coordinator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BF- 4

B. Breastfeeding Promotion, Education and Support Responsibilities

BF- 5

C. Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BF- 5

D. Breastfeeding Promotion, Education and Support Plan. . . . . . . . . . . . . .. BF- 6

V. Participant Education

. BF-7

A. Participant Education Requirements

. BF-7

B. Documentation of Breastfeeding Services. . . . . . . . . . . . . . . . . . . . . . . .. BF- 9

VI. Participant Referral

. BF-IO

A. Referrals

. BF-IO

B. Documentation

. BF-IO

VII. Breastfeeding Materials and Resources

. BF-ll

A. Printed and Audiovisual Materials

. BF-ll

B. Breastfeeding Equipment and Supplies. . . . . . . . .. . . . . . . . . . . . . . . . .. BF-ll

GA WIC PROCEDURES MANUAL FF'96

VIII. Documentation of Breastfeeding Rates.. .. . . . . . .. .. . . . . . . . . . . . . . . . . . . . BF-13

A. DocumentationofWICType.................................. BF-13

B. Documentation of Weeks Breastfed. . . . . . . . . .. . . . .. . . . .. . . . . .. . . BF-14

Attachments

BF-I Position Paper on Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BF-15

BF-2 Merit System of Personnel Administration, State of Georgia Class Title: Senior Public Health Educator - Lactation Consultant. . . . . . . . . . .. BF-16

BF-3 Guidelines for Breastfeeding Promotion and Support intheWICProgram

BF-19

BF-4 Breastfeeding Resources Recommended by the Office of Nutrition

BF-32

BF-5 Allowable and Unallowable Costs for the Promotion and Support of Breastfeeding . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BF-35

BF-6 Issues to Consider When Providing Breast Pumps. . . . . . . . . . . . . . . . . . . . . . .. BF-36

BF-7 Key for Entering Weeks Breastfed. . . . . . . . . .. . . . . . . . . .. . . . . . .. . . . . . . .. BF-39

GA WIC PROCEDURES MANUAL FY'96
L INTRODUCTION
This section ofthe Procedures Manual defines the concept ofbreastfeeding promotion, education and support; and explains the requirements for providing lactation services to WIC Program participants.
In almost all circumstances, health professionals recognize that 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 endocrinologist 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, breastmiIk 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. '
Public Health staff have a responsibility to provide services designed to optimize the Ilealth oftheir 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-l) a sound program ofinformation and support is necessary to promote the successful establishment and maintenance ofbreastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.
IL DEFINITIONS
Breastfeeding promotion, education and support are components ofa process by 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 define a woman as breastfeeding if she either feeds breastmilk to her infant(s), on the average, at least once every 24 hours; or expresses breastmilk with the intention to breastfeed, on the average, at least once every 24 hours.
'Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department ofHealth and Human Services, 1990.
BF-l

GA WIC PROCEDURES MANUAL FY'96
Relactationfmduced lactation after a period ofnot breastfeeding, or by a woman who is not the biological mother ofthe infant also qualifies the woman as breastfeeding.
IlL STATE AGENCY
A. Breastfeeding Coordinator
The responsibility for coordination of Statewide WIC breastfeeding activities is vested within the Georgia Department ofHuman Resources, Division ofPublic Health, Family Health Branch, Office ofNutrition.
A qualified nutritionist (Masters degree and R.D. or eligible for registration.) is designated as the State Breastfeeding Coordinator. the responsibilities ofthis person are to plan, direct and coordinate the breastfeeding promotion, education and support component ofthe WIC Program .
B. Breastfeeding Promotion, Education and Support Responsibilities
The following are the State Agency responsibilities for breastfeeding education, promotion and support:
J. Develop, implement and evaluate the State Breastfeeding Promotion, Education and Support Plan. Periodically review and evaluate, 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 CPA's, paraprofessional staff and clerical staff at local clinics. Training and technical assistance provides WIC
BF-2

GA WIC PROCEDURES MANUAL FY'96
competent professional authorities with current information on the management of normal breastfeeding issues and special problems in lactation. It provides all staff with an understanding ofthe importance of and ways to promote breastfeeding in a clini~ 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 proportion ofthe population needs the information in a language other than English, considering the size and concentration of such population and, where possible, the reading level of the participants.
7. Coordinate WIC breastfeeding promotion, education ana 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 ofbreastfeeding promotion, education and support activities for each local agency on an annual basis. The evaluations shall include an assessment of participant's views concerning the effectiveness ofthe education which they received.
10. Establish standards for participant contact that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.
12. Establish breastfeeding promotion, education and support standards which include, at a minimum, the following:
a. A policy that creates a positive clinic envirorunent which endorses breastfeeding as the preferred method of infant
BF-3

GA WIC PROCEDURES MANUAL FY'96

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 staffinvolved in direct contact with WIC clients.

d.

A plan to ensure that women have access to bre~ifeeding

promotion, education and support activities during the

prenatal and postpartum periods.

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 or health educator. Attachment BF-2 lists a recommended job description for Health Educator Senior, which may be used to fill this position or assure that an individual is qualified to fill this position. An additional job classification is being developed for a nutritionist, through Project Gain. A draft ofthis position may be obtained from the Office ofNutrition.

2. It is recommended that the breastfeeding coordinator work across program lines to provide breastfeeding services, thus assuring that all current and potential WIC participants are reached. This will also serve to integrate services and assure that all clinic staffreceive appropriate training and deliver consistent information on breastfeeding.

3. It is recommended that this position be designated as a full-time position, in order to facilitate coordinating services throughout the

BF-4

GA WIe PROCEDURES MANUAL FY'96
local agency and across program lines, and to adequately meet Federal requirements.
B. Breastfeeding Promotion, Education and Support Responsibilities-
The Georgia WIC Program supports the implementation ofthe Guidelines for Breastfeeding Promotion and Support in the WIC Program. developed by the National Association ofWIC Directors (NAWD) Breastfeeding Promotion Committee (Attachment BF-3). The local agencies are encouraged to use the Guidelines in carrying out the following breastfeeding responsibilities:
1. Establish and maintain a positive clinic environment that clearly endorses and supports breastfeeding as the preferred method of infant feeding (NAWD Guidelines #2, #4).
2. Incorporate task-appropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC participants (NAWD Guideline #1).
3. Develop a plan to ensure that women have access to breastfeeding promotion and support activities during the prenatal and postpartum periods (NAWD Guidelines #3, #5-9).
4. Submit, on an annual basis, a list of activities that are planned for the local agency. These activities should address objectives set out in the State Breastfeeding Plan. At a minimum these activities shall incorporate activities related to Federal requirement for local agencies listed above.
C. Training
1. Orientation
In addition to the training that is to be provided by the local agency to new stafl: during orientation, staff should attend the three (3) levels of the Competency Based Skills Workshops during their first twenty-four (24) months of employment. The Competency Based Skills Workshops are conducted by the Office of Nutrition. These workshops provide WIC competent professional authorities with
BF-5

GA WIe PROCEDURES MANUAL FY'96

current information on nutrition issues, and include a the topic of breastfeeding management in normal and special situations.

2. Continuing Education

a.

All CPA's are encouraged to attend local, State or National

workshops for the purpose ofdeveloping 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 !nplude the name and title ofthe participant, and the title and date ofthe workshop (see Attachments NE-2 and NE-3 for recommended forms).

D. Breastfeeding Promotion, Education and Support Plan

I. Annual Plan of Activities

The State Agency develops an annual Breastfeeding Promotion, Education and Support Plan which incorporates 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 will not need to submit comprehensive plans. Instead, local agencies shaJI submit to the State, by April I of every year, a Plan of Activities based on the State Plan objectives, and recommendations for additions or changes to the State Plan.

a. The local agency Breastfeeding Plan must include:

1) A listing of State Plan objectives that will be addressed by the local agency
2) Action steps, including activities and methods for each objective selected
3) Resources to conduct each objective 4) Milestones of activities for each objective 5) Evaluation design to determine the extent to which
the outcome is commensurate with the Stateobjective

BF-6

GA WIC PROCEDURES MANUAL FY'96
b. The local agency Plan must address, at a minimum, the Federal requirements: prenatal encouragement to breastfeed, establishing a positive clinic atmosphere, incorporation ofbreastfeeding training into stafforientation, and a plan to ensure that women have access to breastfeeding promotion and support during the prenatal and postpartum periods.
c. The recommended format for submission of the Breastfeeding Plan can be found on Attachments NE-l and NE-4, with exclusion of the Needs Assessment.
2. Breastfeeding Plan Update
a. The Update is a progress report and must be submitted to the Office ofNutrition by December 1 of each year. The update must include the following:
1) Brief description of milestones accomplished in the previous Federal Fiscal Year
2) Revision, deletion, and/or addition of objectives addressed
3) Revision, deletion, and/or addition of action steps
b. The recommended format for submission ofthe Update can be found on Attachment NE-5.
v. PARTICIPANT EDUCATION
A. Participant Education Requirements
1. The Nutrition Guidelines for Practice are the established guide for breastfeeding education. Guidelines for Practice manuals are located in each health department and with each local agency nutrition coordinator.
2. All pregnant participants must be encourage to breastfeed unless contraindicated for health reasons. As recommended in the Nutrition Guidelines for Practice, encouragement to breastfeed should continue throughout the prenatal period.
BF-7

GA WIC PROCEDURES MANUAL FY'96
As stated in the Healthy People 2000 National Health Promotion and Disease Prevention objective s 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. Breastfeeding women may receive WIC benefits for up to one (1) year while non-breastfeeding women are eligible for only six (6) months postpartum.
c. The WIC Program offers a greater variety and quantity of food to breastfeeding participants than to non-breastfeeding, postpartum participants.
4. Breastfeeding women should be taught hand expression ofmilk if they are comfortable with the idea and interested in learning it. All staffshould be trained to teach hand expression ofbreastmilk. However, ifa staff person is not skilled in this area, a referral should be made to trained staffor the local agency breastfeeding coordinator.
5. Breastfeeding education contacts must be provided by a nutritionist, registered dietitian, registered nurse, licensed practical nurse, physician, physician's assistant; or other certified health professional, peer counselor or paraprofessional that has been
~ealthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.
BF-8

GA WIC PROCEDURES MANUAL FY'96

trained by the State or local agency.

6. 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.

7. Paraprofessionals can also provide breastfeeding education and support when appropriate training has been received. The training plan must be approved by the Office ofNutrition (See Attachment NE-6 for the Guidelines for Paraprofessional Training and list of items to be submitted for approval).

8.

An individual care plan should be developed for a particfp~t based

on the need for such plan, as determined by the competent

professional authority. The Care Plan should be written in the

progress notes, preferably using the SOAP (S-ubjective - Qbjective -

Assessment - Ian) note format.

9. A lesson plan must be developed when group classes are used to provide the breastfeeding education contact. Lesson plans must be kept at the clinic site for use by clinic staff, and provided to the Office ofNutrition at the time of program reviews.

10. If the participant/caregiver is unable to receive services at the clinic for an extended period oftime, home visits are the recommended method for providing breastfeeding education contacts.

11. Local agencies are also encourage to provide ongoing lactation support for prenatal and breastfeeding women by telephone. If possible a breastfeeding hot-line should be established to facilitate access to information and support services.

B. Documentation ofBreastfeeding Services

1. All breastfeeding education and support contacts received by participants must be documented in the participant's health record. A tickler card is considered part of the permanent health record, although it may be kept in a separate tickler file.

a. In order to facilitate continuity of care, documentation of encouragement to breastfeed should include all aspects of

BF-9

GA WIC PROCEDURES MANUAL FY'96

breastfeeding discussed with the participant (e.g., barriers to breastfeeding; emotional and nutritional advantages of breastfeeding, positioning, etc.).

b.

The POMR. ~roblem Qriented Medical E,ecord)/SOAP

note format is the recommended method of documentation.

A flow sheet may be used as long as it contains all

components ofa SOAP note.

c. Group breastfeeding education contacts may be documented with the participant's signature on a class attendance sheet or voucher register. There must also be a class 4.e~cription with the date, lesson objective(s) and the original signature ofthe staff conducting the class. A description ofthe district's method ofdocumentation must be submitted for approval prior to implementation.

2. Missed appointments for breastfeeding education contacts and the refusal of a participant/caregiver to receive nutrition education must be documented in the participant's health record.

VL 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 staffwith expertise in handling breastfeeding questions, sources for breastfeeding pumps, peer counselors, etc.

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

BF-IO

GA WIC PROCEDURES MANUAL FY'96
refusal by the participant must also be documented.
vn. BREASTFEEDING MATERIALS AND RESOURCES
A. Printed and Audio-Visual Materials
Standards for 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 of the Procedures Manual for information). Attachment BF-4 provides a list of resources that are recommended for use by the Office ofNutrition.
B. Breastfeeding Equipment and Supplies
1. Allowable Costs
Local agencies are encouraged to assess the need for breastfeeding equipment and supplies. Providing these should not genera1ly be the primary means by which the State and local agencies meet their breastfeeding 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 inducement to consider or to continue breastfeeding.
The policy on allowable costs for the promotion and support of breastfeeding is provided in the Administrative Responsibilities section of the Procedures Manual. Attachment BF-5 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 manuallyoperated 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:
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GA WIC PROCEDURES MANUAL FY'96
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 and adequate milk supply due to maternal illness or a premature/sick infant.
c. Mothers with inverted/flat nipples who are having latch-on problems.
d. Mothers attempting to build their milk supply fOl:"a,ny reason.
e. Mothers choosing to express breastmilk for missed feedings due to work, school, 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 State agencies may choose to offer to certain WIC participants to facilitate breastfeeding. Ifa State or local agency chooses to provide breast pumps, the pumps may be offered free or at a cost to WIC participants. Issues to consider when providing breast pumps are explained in further detail in Attachment BF-6.
3. Instructions for Breast Pump Use
Local agencies with breast pump loan and give-away programs must establish written policy and procedures regarding appropriate usage 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 breast pump 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 ofthe breast pump before leaving the issuing facility.
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GA WIC PROCEDURES MANUAL FY'96
c. Follow-up within a 24-hour period is recommended, in order to assure that the pump is operating correctly and that the mother is using it properly.
VITI. DOCUMENTATION OF BREASTFEEDING RATES
The Georgia WIC Program documents breastfeeding rates by two different methods: percentage of women who are certified as breastfeeding (Type B), and self-reported information on weeks breastfeed (initiation). 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 ofWIC Type
The State agency must have breastfeeding promotion and support expenditures which are based on the number of prenatal and breastfeeding women 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 (Type B on the WIC System). Breastfeeding women should be entered into the System in the following ways:
I. A prenatal woman gives birth and is being certified as breastfeeding.
2. A prenatal woman gives birth and is updated as a breastfeeding woman. This action may take place prior to her subsequent certification as breastfeeding. This serves to capture those women who initiate breastfeeding, but may discontinue breastfeeding by their subsequent certification.
3. 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 can be certified as breastfeeding as long as the definition of breastfeeding is met, i.e., the infant is offered breastmilk on the average once a day (see IT. on page BF-I) .
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GA WIe PROCEDURES MANUAL FY'96
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 staffwho complete The WIC Assessment/Certification Forms and the Turnaround Documents be instructed on the importance and the process for accurate documentation ofweeks breastfed. It is a requirement that the weeks breastfed be completed 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: one year of age certification visit 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 oftime 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-7 for appropriate codes to use for weeks breastfed.
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GA WIC PROCEDURES MANUAL FY'96

ATTACHMENT BF-l

- < ~ . ~ , - . ~r-::2,""p"'ea-ch1r=ee"",""St<::::ee=~"N7.'W"",""AtIa=n:::taG"""',eor=g"'ia'"'3"'030=3-.---~-

POSITION PAPER ON BREASTFEEDlNG

If (he 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 ideal fint food foc the human inf:..nt. In .addition to the nutritional benefits for the infant, this method offceding offers unique physiological and psychological advantages to both the mother and the infant. Every infant. therefore, should receive the benefits of this ideal c'hoicc for infant feeding. This paper presents the rccommendationsoftheSu.te ofGeorgia forencour:aging breastfceding and defines the advantages of breastfeeding for the health of blothers and infants.

No formula., no matter how "humanized", can take the place ofhuPUUllDilk. Decreased infant P10ftality 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 becallSC:

breast milk provides an ideal balance of uutrieU" for the human infant the nutrients in breast milk arc easily absorbed and digested breast milk contains immune facton and antiinfec:tive properties that protect against infections breastfeeding allows the satiety mechanism in the infant to develop naturally infants who are breJl$tfcd have fewer allergies brcastfceding pumits increased bonding between. mother and infant breast m~lk 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 prcnataland postpartum periods. Based on the World Health OrganizationfUnited Nations Intenudional Childrens' Fund (WHOIUNICEF) 1979 meeting on Infant and Young Child Feeding, the WHO 1981 Resolution and the recommendation of the American Academy ofPediatrics Committee on Nutrition.. the Georgia Department of Human RC$ources recommends that:

breast milk be the "house fonnula" in all hospitals in Georgia where matel"llity services are offered

all expectant parents be informed of the numerous advantages (both to infant and mother) of

breastfeeding.

every expectant mother receive pradical information on how to initiate and maintain lactation..

obstetrical procedures and practices be consisteat wit&. the policy of promoting breastfeeding.

breastfeeding be initiated as soon as possible, preferably dUring the fint hour aner birttl.

every hospital permit and encourage rooming-in and oD~emand feeding of breastfed infants.

infant formulas not be marketed or distributed in ways that may interfere with the protection and

promotion of breastfeeding.

places of business. including govemmea.t off'lCUo facilitate the maintenance of laetation through

liberalized policies tbt would promote breastfeeding.

.

AU 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 milkas this choice Cor infant nutrition wiu promote optimum health for future generations of Georgians.
/~
Ptltrlck.1. Meehan, M.D. Director Division of Public Health

July, 1994

AN EQUAL OPPORTUNITY EMPLOYER

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GA WIC PROCEDURES MANUAL FY'96

AITACHMENT BF-2

MERIT SYSTEM OF PERSONNEL ADMINISTRATION STATE OF GEORGIA
Class Title: SENIOR PUBLIC HEALTH EDUCATOR - LACTATION CONSULTANT
The examples ofworlc given are illustrative ofthe duties assigned to positions ofthis class. No attempt is made to be exhaustive. The intent ofthe listed examples is to give a general indication ofthe levels of difficulty and responsibility common to all positions ofthis class.
The standards for training and experience express the minimum background necessary as evidence of an applicant's ability to quaIiJY for positions ofthis class. Unless otherwise stated, the Applicant Services division may allow substitution ofappropriate education or experience for the training and experience ~umlisted.
DEFINITION
Under direction, perfonns work ofmoderate difficulty in planning and implementing breastfeeding education activities related to public health prograntS; and perfonns related work as required.
EXAMPLES OF DUTIES
I. .Coordinates breastfeeding promotion project. Writes, revises and evaluates the district's breastfeeding services.
A. Establishes relationship with community health centers and/or hospital staff to provide breastfeeding services.
B. Provides inservice education material and/or needed equipment on breastfeeding for staffdevelopment.
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 initial visit to breastfeed by providing an array of educational material and counseling.

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GA WIe PROCEDURES MANUAL FY'96
GEORGIA MERIT SYSTEM PAGE 2

ATTACHMENT BF-2 cont'd

B. Provides additional breastfeeding counseling to prospective breastfeeding women during the last trimester through breastfeeding classes and/or individual counseling.

C. Provides postpartum assessment ofbreastfeeding 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 tJ!r9ugh a

variety of methods, such as support groups, peer counselors, etc.

-

E. Supervise and train peer counselors.

F. Has ability to communicate effectively in writing, including grant proposals.

ill. Evaluates effectiveness of breastfeeding program activities.

A. Produces reports to determine breastfeeding rate and duration.

B. Assists WIC Nutrition Coordinator in writing breastfeeding promotion plan and annual update ofbreastfeeding activities and progress.

C. Shares reports at local district meetings and Statewide breastfeeding conferences.

IV. Attends inservice education programs and annual Statewide breastfeeding conferences.
v. Other miscellaneous duties, activities and responsibilities as program needs
develop and change, and as assigned.

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ATIACHMENT BF-2 cont'd

GEORGIA MERIT SYSTEM PAGE 3

MINIMUM QUALIFICATIONS NECESSARY KNOWLEDGE, SKILLS, AND ABILITIES

Considerable ability to assess the effectiveness and needs ofa lactation 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 oflactation 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 breastfe~ing program.

Good working skill 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 program; in making recommendations for equipment needs; and in ability to budget.

TRAINING AND EXPERIENCE

Completion of a masters degree in public health education, education, nursing, home economics or a field directly related to public health activities. Has successfully completed the State certification or equivalent.

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A'ITACHMENT BF-3

POSITION PAPER NATIONAL ASSOCIATION OF WIC DIRECTORS
April 1994
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 lind 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.
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ATfACHMENT BF-3 cont'd

GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless oftheir breastfeeding patterns.
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:
clinic environment policies program goals and philosophy regarding breastfeeding 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:
culturally appropriate breastfeeding promotion strategies current breastfeeding managementtechniques to encourage and support the breastfeeding mother and infant
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ATIACHMENT BF-3 cont'd

appropriate use ofbreastfeeding education materials identification ofindividual 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:
statewide and local conferences and workshops 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:
print and audiovisual materials free offormula product names office supplies such as cups, pens and note-pads free offormula product names
Rationale: Use of materials with product names sends a mixed message to
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AITACHMENT BF-3 cont'd

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 offormula and bottlefeeding equipment. Consider:
storing supplies offormula out ofview ofparticipants storing baby bottles and nipples out ofview ofparticipants
Rationale: Formula and bottle-feeding equipment in clear view of participants may influence a mother's decision on infant feeding.
4. It isimportant that staffnot 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:
chairs with arms a breastfeeding area away from 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 WICstaff.
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
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GA WIC PROCEDURES MANUAL FY'96
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:
task forces, networks or steering committees to exchange information and strategies professional health organizations to secure resources and expertise and assure communication with health professionals serving pregnant and . breastfeeding women existing peer support groups to facilitate local exchange ofbreastfeeding information across the state community leaders and citizen groups who support breastfeeding
the Breastfeeding Promotion Consortium and its efforts, including a national 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:
American Academy ofPediatrics American Academy ofFarnily Physicians American college of Nurse Midwives American College of Obstetricians and Gynecologists American Dietetic Association American Hospital Association American Nurses Association
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A'ITACBMENT BF-3 cont'd

American Public Health Association Association ofPediatric Nurse Practitioners Association ofWomen's Health and Obstetrics Nurses Healthy Mothers, Healthy Babies Coalitions International Lactation Consultants Association La Leche League International Maternal and Child Health Directors Medicaid Directors National Association ofPediatric Nurse Associates and Practitioners
Rationale: Serving as an adjunct to health eare is a vital component of the WIC Program. Therefore, it is important that the program's healt]1: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:
co-sponsoring training and continuing education programs sharing breastfeeding education materials for clients 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 are incorporated in relevant educational activities, materials and outreach efforts.
Suggestions for Implementation
1. It is important that positive breastfeeding messages are used in:
participant orientation programs and materials printed and audiovisual materials for professional audiences 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.

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GA WIC PROCEDURES MANUAL FY'96

ATTACHMENT BF-3 cont'd

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:

incorporation ofdata collection into current WIC systems

periodic sample sUIVeys of program participants

Centers for Disease Control and Prevention sUIVeillance systems

state suIVeillance systems

-~

birth certificate information

Rationale: Since few data are available, data collection wiD help identify and direct further breastfeeding promotion efforts for this population. Assessment of successful strategies wiD help agencies measure progress toward meeting the health objectives for the nation.

2. If more in-depth information on the incidence and duration ofbreastfeeding is desired, it is important that information be collected on at least the following categories:

exclusive breastfeeding patterns of cOnibined breastfeeding and formula feeding, e.g.:
mostly breastfeeding equal parts breastfeeding and formula feeding mostly formula feeding 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.

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 sUIVey.

Rationale: Collecting data on breastfeeding attitudes, infant feeding. practices and WIC-related promotion activities about breastfeeding assists

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GA WIC PROCEDURES MANUAL FY'96

ATTACHMENT BF-3 cont'd

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:

participant orientation and education materials

policies regarding formula samples and food package tailoring for

breastfeeding mothers and infants

clinic environment, including display materials and posters, and visibility of

formula supplies

staff interaction with participants regarding the infant feeding d~_sion and

breastfeeding support

.

local agency linkages with other community programs providing services to

breastfeeding women

stafftraining plans

Rationale: Guidelines and policies must be implemented in order to affect breastfeeding initiation and duration rates ofWIC 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:

integrate breastfeeding promotion into the continuum ofprenatal nutrition education include an initial assessment of participant knowledge, concerns and attitudes related to breastfeeding provide breastfeeding education and support sessions to each prenatal participant based on the above assessment define the roles of all staff in the promotion ofbreastfeeding define situations when breastfeeding is contraindicated establish referral criteria

Rationale: Making informed choices regarding the best metbods of infant feeding is, in part, dependent on staff's ability and efforts to address women's
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GA WIC PROCEDURES MANUAL FY'96

ATTACHMENT BF-3 cont'd

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:

peer counselors an honor roll of successful breastfeeding WIC participants an opportunity to watch other WIC participants breastfeed 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 ofthe 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:

discussing WIC's position about breastfeeding as optimal for most women and infants encouraging the sharing of educational materials between WIC and primary care providers 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.

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ATIACHMENT BF-3 cont'd

6. It is important that the local WIC agency know the breastfeeding practices oftheir community hospitals and primary health care providers.
Rationale: Local agency WIC staffshould be part ofthe prenatal care team preparing women for their early breastfeeding experien~es. 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 ofbreastfeeding (the practice offeeding 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 ofwomen 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 oftheir 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.

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GA WIC PROCEDURES MANUAL FY'96

ATTACHMENTBF~co~d

Suggestions for Implementation
1. It is important that the use ofsupplemental 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.
2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. Ifa 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 offormula 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 ofthe 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.

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ATTACHMENT BF-3 cont'd

Rationale: Offering formnla 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
l. 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:
Include professional support, such as management oflactation problems, hotline contacts and telephone counselors 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 successfuUy 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:
mothers returning to paid employment or school; mothers separated from their infants due to hospitalization or illness; mothers of multiples; infants with special needs 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 ofbreastfeeding. Consider:

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ATIACHMENT BF-3 cont'd

using appropriate posters and messages placed in the clinic waiting and nutrition education areas including a special breastfeeding message, on vouchers, encouraging the continuation ofbreastfeeding
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:
Maternal and Child Health Family Planning hospitals Indian Health Service 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 distribution ofbreastfeeding aids, including:
circumstances when the breastfeeding aid might be provided 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-4

BREASTFEEDING RESOURCES RECOMMENDED BY THE OFFICE OF NUTRITION

PAMPHLETS (All ofthe pamphlets listed below are also available in Spanish)



Breastfeeding: Near to the Heart, the Office ofNutrition, 1994.



Congratulations To Grandmothers, Best Start, Inc. (#1020)



Congratulations To Fathers, Best Start, Inc. (#1021)



Breastfeeding Is Easy To Learn, Best Start, Inc. (#1022)



Breastfeeding Won't Keep You From Doing What You Want To Do, Best Start,

Inc. (#1023)

-,



Breastfeeding Can Help You Share A Special Bond With Your Baby, Best Start,

Inc. (#1024)



Breastfeeding Can Make You Feel Good About Yourself, Best Start, Inc. (#1025)



Breastfeeding Doesn't Have To Change The Way You Eat, Best Start, Inc.

(#1026)



Breastfeeding Doesn't Have To Be Embarrassing, Best Start, Inc. (#1027)



Breastfeeding Can Make Your Family Proud Of You, Best Start, Inc. (#1028)



Breastfeeding Doesn't Have To Tie You Down, Best Start, Inc. (#1029)

BOOKS AND MANUALS



Breastfeeding: A Guide for the Medical Profession, by Ruth Lawrence

C.V. Mosby Co., St. Louis, MO, 1994.



Breastfeeding: A Problem-Solving Manual, by Stephen Saunders, et. al.

Essential Medical Infonnation Systems, Inc., Dallas, TX, 1990.



Breastfeeding & Human Lactation, by Jan Riordan and Kathleen Auerbach

Jones & Bartlett, Publishers, Boston, MA, 1993.



The Breastfeeding Answer Book, by La Leche League International

La Leche League International, Franklin Park, IL, 1991.

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GA WIC PROCEDURES MANUAL FY'96

ATIACHMENT BF-4 cont'd



Breastjeeding Triage Tool, by Sandra Jolley

Breastfeeding Promotion Project, Seattle-King County Public Health, Seattle, WA,

1990.



Counseling the Nursing Mother: A Reference Handbookfor Health Care

Providers andLay Counselors, by Judith Lauwers and Candace Woesner

Avery Publishing Group, New York, NY, 1983.



Drugs in Pregnancy and Lactation: A Reference Guide to Fetal & Neonatal Risk,

4th Edition, by Gerald G. Briggs, et. aI.

Williams &Wi1kins, Baltimore, MD, 1990.



Nursing Mother's Companion, by Kathleen Huggins

Harvard Common Press, Boston, MA, 1990.



Nutrition During Lactation, by the Institute ofMedi~ine, National Academy of

Sciences

National Academy Press, Washington, D.C., 1991



Nutrition Guidelinesfor Practice, by the Office ofNutrition

Office ofNutrition, Family Health Branch, Division ofPublic Health, Georgia

Department ofHuman Resources, Atlanta, GA, 1995.



A Practical Guide to Breastjeeding, by Amy Kathryn Spangler

Amy Kathryn Spangler, Atlanta, GA, 1994.



Womanly Art ofBreastfeeding, by La Leche League International

La Leche League International, Franklin Park, lL.

VIDEOTAPES



Best Start: For All the Right Reasons, (also available in Spanish), Best Start, Inc.,

Tampa, FL.



Best Start: Training Program, Best Start, Inc., Tampa, FL.



Breastfeeding Your Baby, The Office ofNutrition, 1994.

BF-33

GA WIC PROCEDURES MANUAL FY'96

A'ITACHMENT BF-4 cont'd



Yes, You Can Breasifeed, (also available in Spanish), Texas Public Health.

Available from Metro Post, Attn: Ecko, 501 N. IH 35, Austin, TX 28273;

(512) 476-3876.

TEACHING TOOLS



Breast Model

Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602



Flip Chart

Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602



BabyModel

Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602

TELEPHONE INFORMATION SERVICES FOR HEALTH PROFESSIONALS



Georgia Poison Control Center

Grady Memorial Hospital, Atlanta, GA

(404) 616-9000 or (800)282-5846

Service Provided: Answers to questions on Drugs and Lactation

Charge: There is no cost for this service



Breastjeeding andHuman Lactation Study Center

University ofRochester School ofMedicine & Dentistry, Box 777, Rochester,

New York, 14642

(716) 275-0088.

Service Provided: Data base to assist with questions about pharmaceutical drugs

and breastfeeding. Provides bibliographies on breastfeeding and lactation.

Charge: None, beyond cost oftelephone call



The Lactation Program

1719 E. 19th Avenue, Denver, CO, 80218

(303) 869-1881

Service Provided: Phone consultationwith lactation consultants for difficult

breastfeeding questions.

Charge: None, beyond cost oftelephone call

BF-34

GA WIC PROCEDURES MANUAL FY'96

ATIACHMENT BF-5

ALLOWABLE AND UNALLOWABLE COSTS FOR THE PROMOTION AND SUPPORT OF BREASTFEEDING

ALLOWABLE COSTS
The cost ofbreastfeeding aids which 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:
Breast pumps Breastshells Nursing supplementers Nursing bras Nursing pads .Costs associated with the purchase and availability ofbreastfeeding aids
through the WIC Program, such as insurance and service fees in providing breast pumps Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. For example: breast models, breastfeeding aids, dolls to illustrate nursing, etc. Other items which can be shown to directly support the initiation and continuation ofbreastfeeding.
UNALLOWABLE COSTS
Breastfeeding aids which 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.

BF-35

GA WIC PROCEDURES MANUAL FY'96

ATIACHMENT BF-6

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 manual or 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 ofthe 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 ofthe 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 Office ofNutrition 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 ofManagement and Budget circulars A-87, Attachment A, paragraph C.3., and A-122, Attachment A, paragraph A.S.

BF-36

GA WIC PROCEDURES MANUAL FY'96

ATIACBMENT BF-6 cont'd

Loaning Breast Pumps and Liability Issues
Manual breast pumps, attaclunent 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 one-person use ofa manual pump. In addition, the small electriclbattery-operated pumps are often not durable enough to be used repeatedly, and their cost is also minimal.
Since large electric breast pumps represent a significant investment ofWIC resources, loaning them is the only option. However, under this option, local agencies that directiy purchase breast pumps for loan to participants may incur the financial liability oflost or damaged breast pumps. These pumps should be loaned in combination with so"ine 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 ofbreastfeeding or for certain medical conditions; and
e. charging a refundable deposit.
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 ofthe lost or damaged breast pump could easily exceed the value of the pump itself. Building a relationship oftrust with WIC participants may minimize the risk of 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
BF-37

GA WIe PROCEDURES MANUAL FY'96

ATIACHMENT BF-6 cont'd

provided with breast pumps by the WIC Program must be instructed on proper pump use.

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 part with whom they 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.

-,

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 ofsupport 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 oftime 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 ofthe equipment. In these cases, the local agency staff should provide the necessary information and follow-up to the WIC participant.

BF-38

GA WIC PROCEDURES MANUAL FY'96

ATI'ACHMENTBF-7

KEY FOR ENTERING WEEKS BREASTFED

The number of weeks breastfed must be entered on the WIC Assessment/Certification Form and Turnaround Document for:



Breastfeeding Women: initial and six-month certification visits



Postpartum, non-breastfeeding women: certification visit



Infants: initial certification and mid-certification nutrition assessment visits



Children: one-year of age certification visit

Length oftime 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

00 = Never breastfed 01 (weeks) = One time to 10 days 02 (weeks) = 11 to 17 days 03 (weeks) = 18 to 24 days 04 (weeks) = 25 to 31 days 05 (weeks) = 32 to 38 days 06 (weeks) = 39 to 45 days 07 (weeks) = 46 to 52 days 08 (weeks) = 53 to 59 days ETC.

II. Codes to Enter When Breastfeeding is Given in Months

Ifthe length ofbreastfeeding is given in months, simply multiply by four (4) to calculate the number ofweeks breastfed.

Example: A woman stated she breastfed her infant for 5 months. Calculate weeks breastfed as follows:

5 x 4 = 20 weeks

Enter 20 on the in the appropriate space for Weeks Breastfed, on the WIC Assessment/Certification Form and the Turnaround Document.

BF-39

GA WIe PROCEDURES MANUAL FY'96

ATIACHMENT BF-7 cont'd

Sources:

Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division ofNutrition, Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department ofHealth and Human Services, Public Health Service. November J989
Georgia WIC User Manual, 1994.

BF-40

I. General
Attachment: DP-I Disaster Plan

TABLE OF CONTENTS Page
.................................... DP-I

.

.

.DP-2

I I I I I I I I I I I I I I I I I I I I I

GA WIC PROCEDURES MANUAL FY '96 DP-l

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
I

GA WIC PROCEDURES MANUAL FY '96

Attachment DP-I

GEORGIA WIC PROGRAM
DISASTER PLAN FFY'96

DP-2

\ V\ )L-

Table of Contents

I. Introduction

A. Purpose B. Scope

II. Policies

III. Situation

IV. Concept of Operations

A. General.

:

B. Organization (state and local agency responsibilities)

C. Notification

V. Responsibilities

A. Facilities

B. Issuance

C. Certification

,

D. Nutrition Education Contacts

VI. Resource Requirements

A. Staff , B. Infant Fonnula C. Food Instruments D. Transportation

Page DP-l
DP-l DP-l
DP-2
DP-2
DP-3
DP-3 DP-3 DP-5
DP-5
DP-5 DP-5 DP-7 DP-7
DP-8
DP-8 DP-8 DP-9 DP-9

DP-A.... DP-B DP-C DP-D.......

Attachments

DP-Page 10 DP-Page 11 DP-Page 12 DP-Page 13

GEORGIA STATE DISASTER PLAN

I. INTRODUCTION

In contrast to commodity distribution of food stamps, WIC is a limited grant supplemental food program that serves a specific population with special nutritional needs. WIC is not designed or funded to meet the basic nutritional needs of disaster victims who would not otherwise be eligible for the program. Unlike the distribution of commodities or the emergency issuance of food stamps, there is no legislatively mandated role for WIC in disaster relief, nor is there legislative authority for using WIC food funds for purposes other than providing allowable food benefits to categorically eligible participants. Finally, no additional WIC funds are designated by law for WIC disaster relief, and WIC must operate in disaster situations within its current program context and funding. For these reasons, WIC is not to be considered a first-line of defense to respond to the nutritional needs of disaster victims, including the provision of infant formula.

A. Purpose

The Purpose of this Disaster Plan is to:

1. Restore WIC services to current participants as soon as possible.

2. Expand services to more of the eligible population in the disaster affected areas.

B. Scope

These guidelines reflect the Operating Plan to be followed by the State ~~ Agency in the event
of a disaster or emergency creating a disruption in service delivery aiil local agency. WIC
local agency staff will be guided by their County Public Health Departments and District Procedures. Private agencies, which contract to provide WIC services, will use the disaster plans that are consistent with these and any developed by their parent agencies. State WIC Office guidelines will reflect the purpose, authority, and responsibilities developed by the l!il:HR
Emerg,,~i(?YP1@:~t';W1l5Ii~:Ja:~a:ltllJ;

if.lie.Ge(}tg~~~G~-3@i:#W-'W~~9.m.M~~@i.WW5'.@w~W[@~mN4~%W a!i.m~-ely eiltireIy.0.!'1.otli,(W:~1i.5llStet;.~~iJ1J.fl:!~!ll.ti~N;(i:., Art1citiClili.!diCiOss;:.:i1iv.:#/im.l:!'iM!, cllW,hes
ect.) l1tltil.it'15feasiqlt(t'o~*-a(e;a(jil'@t.;.ijiSttibjitiPitsy:stifuj()tl1#fil-tllll.;i:liSfribjitiOl~ is available,

we In the cvcilt oL~uspc~lo1ll)ft1ie:WICl?tpg~hdUring thii;periQ<i, the $tatc

Office willJilakc

copies av'ailabliiohhe Fo6dpantiiesn.ii(FFooiJ Assistance Program Booklelto the appropriate

The Emergency numbers for contacting the American Red Cross is aIt'j:;attached to this Plan (Attachment D). The contact person as well as the fax number is also available in (Attachment D).
II. POLICIES
Specific decisions concerning state agency actions during a disaster depend upon the duration and magnitude of the disaster, and upon specific directions from the State Health Director. The focus of State WIC Agency activity is to support local agency service delivery. These guidelines primarily reflect state agency responsibilities in the event of disruption of services in one local agency. In the event of an emergency at the state agency, state agency personnel will follow the rules developed by the State Health Director. In the event of a disaster or emergency involving both local and state agencies, the initial focus of the state agency will be to estimate the impact and determine the measures needed to support the restoration of services by the local agency. The state and local agencies will develop provisional operational policies following a disaster that respond to the specific needs created by the disaster.
III. SITUATION
The extent of damage caused by the disaster must be assessed. To determine if delivery of services is feasible, the following questions should be answered:
1. Is the Health Department/Local agency requesting help?
2. How many participants are affected, can they reach food instrument issuance sites, and are the issuance sites operational?
3. How many grocery stores are closed due to the disaster and is retail purchase still feasible?
4. How many persons are made newly eligible as a result of the disaster? Would income be computed? Monthly or annually?
2

5. Are electric, water, communication ~~:~~Bc,l*~\l1# services disrupted?
6. How long could services be disrupted?
7. What alternative to current policies and procedures must be made?
IV. CONCEPT OF OPERATION
A. General
A Disaster Plan folder will be kept in the State WIC Office Director files and the Director of the Office of Nutrition. Included in the Disaster Plan folder are the currerit phone listings for the Regional Food Nutrition Services Offices, County Public Health Unit Disaster Coordinators, State Health Office Disaster Coordinators, statewide and local chapters of the American Red Cross, Department of Agriculture Food Distribution Program, and other non-profit and private programs. The folder will also contain a listing of home addresses and phone numbers of selected State WIC Office and Nutrition Services staff. Home addresses and phone numbers are confidential and will only be used in an emergency.
B. Organization
Director Responsibilities
The Director responsibilities will be to:
1) contact formula manufacturer to secure RTF formula, nipples and bottles. 2) follow through on arrival/receipt of formula 3) visit area to make on-site assessment support staff etc.
State Level Responsibilities
Various staff members have responsibilities in the WIC and Nutrition Services Disaster Plan. The overall responsibility for implementation and reporting on WIC's response to the disastet lies with the Director of WIC and Nutrition Services or designee. The Unit Managers and Consultants will have responsibilities related to coordination of staff and analysis of requirements resulting from the disaster. The Systems Information Unit (in conjunction with local WIe Program Coordinators) will be responsible for the coordination of mass supply shipment, storage and responsibilities related to coordination of participant food instrument issuance, including remote printing, equipment issues and emergency procurement of vouchers. The Financial Unit has the responsibility of tracking and reconciling costs relating to the disaster. The Manager of the Ouality Assurance Unit will have responsibilities related to insure documentation for the use of vouchers. Staff
3

would be assigned to serve at the location according to a schedule. The Manager of the Vendor Unit will have responsibilities of providing the local agency with operational authorized WIC vendor sites. The Office of Nutrition Consultants will have responsibilities related to certification and food package issuance, Nutrition Education and Food Safety Preparation, Breastfeeding Education and support infonnation. All contracts for fonnula procurement by Georgia WIC and Nutrition Services will contain a clause addressing alternative measures for acquisition and distribution of infant fonnula in the case of a disaster.
STATE AND LOCAL AGENCIES
The state and local agencies will coordinate efforts to obtain the appropriate type and quantity of staff to assist the local agency in need. Staff may be assigned from within the county, from another county, from another District or from the state agency to meet a specific county's needs during a disaster.
The state and local agencies may be asked to provide staff at a designated Disaster Assistance location (not always a Health Department facility) in order to provide WIC services more expediently.
Following a disaster in which state or local agency offices are closed, staff should report within eight (8) hours to one of their supervisors to report their sitnation and availability for duty assignments. If none of the local agency's immediate supervisors can be reached, local agency staff can call the State WIC Office at 1-800-228-9173 to report their status and phone number where they can be reached. Attachment A is a fonn designed to collect data for this purpose.
Staff Documentation Requirements:
1. Any office which has staff working on disaster activities must maintain a Disaster Office Employee Log, Attachment B. One log per office should be maintained per pay period and kept on file.
2. Any departmental employee working on disaster activities should immediately begin to maintain a Disaster Daily Work Activity Log, Attachment C. The completed activity logs should be retained by each departmental employee. If Federal Emergency Management Agency or other funding sources become available, the Disaster Daily Work Activity Logs will be used to help document staff time for federal reimbursements.
4

C. Notification
Lines of communication during a disaster would begin with sites contacting the main local agency office. Local agencies would contact their County Health Department and District Disaster Coordinators. The state agency disaster plan will be implemented following notification from the local WIC Coordinator, who has cleared these plans with his or her District Disaster Coordinators. The State WIC Office would contact the State Health Office Disaster Coordinator and appropriate WIC retail vendors. The State Office will contact State Coordinators.
v. RESPONSIBILITIES
A. Facilities
During a disaster, it is imperative that the safety of staff/participant be considered. Therefore, it may be necessary to move to another location. In the event of a move, an immediate survey should be taken of all state buildings and offices in the affected area(s) to identify damage or nature of incident.
Necessary emergency action should be taken to protect WIC Programs property where state buildings or offices have been damaged. This ~ include, but is not limited to, moving contents and equipment files, acquiring security services, securing buildings, or other necessary activities.
The records and invoices of any repair activity should identify the site location and/or facility address to assist in the filing of insurance claims. This information must be reported to the State WIC Financial Unit.
The state agency will cooperate with the local agency to identify buildings, equipment, medical services, general supplies, and any other resources required to continue service delivery. This will include assisting in locating potential points for direct distribution of infant formula and food. The state/local agencies will select and arrange to use those facilities and locations that are most accessible to participants. Whenever' possible, the state agency will coordinate communications and services with other state program offices, such as Maternal and Child Health, Aid to Families with Dependent Children, Food Stamps, and Disaster Assistance Centers.
B. Issuance
During periods of emergency or disaster, every effort will be made to continue issuance of food instruments to participants. When adverse circumstances persist, such as the lack of available facilities, records or food instrument supplies, the state agency will coordinate
5

efforts with the local agency to ensure ~1 a minimal supply of food or food instruments
- - ~~~~~;I~:~~'~~~'~~~I;if~;~~:~;~~!~~~~~i~~h~~~j~b:a#~ t6or<letil.jJf.iro@a:teiUi.1()iliifS{al9jW})llll.gliim~~abIeiiipl'.;t~%(~:rl>(lttle~) ."1\s 'soon astli disastetllfsa.tettIi:Ifs.t9.not@l.H)t;;I~f@,qtli~r.;~~~ncYil.~ptsrespohSibi~itY.for'forIIuiJA, d.iSti.iblltion.fotre:lil)'~t(;Meci1;fof'ihtilii,*.urJ)e;.4iscontiiiti.@; .A.dult and child participants will be directed to emergency food centers in the event that direct distribution is necessary.
1. Retail Grocery Stores: The state and local agency will establish and maintain a list of retail grocery stores that remain in operation following the disaster, their operating hours, and their available stock of WIC approved foods. The state and local agency will coordinate efforts to share this information with the participants.
2. Direct Distribution: If retail purchase is not viable, then direct distribution measures will be considered. The local agency, State Staff, aIidDisaster Coordinator will determine when retail purchase is considered not viable when a significant number of clients are unable to purchase WIC approved foods. This could be due to the closure of many retail stores, the inability of many clients to get to a retail store, or disruption of the supply of food to stores.
State and local agencies will coordinate efforts to contact the Red Cross and other relief agencies to arrange for methods of food distribution to current participants and to newly eligible participants. The state agency will arrange for the supply and distribution of food items and/or food instruments to the local agency in need. For those local agencies in close proximity to the state agency, the state agency may become directly involved with the distribution. If the district office is closer in proximity, efforts will be made by the State Office to coordinate distribution to the local agency through the district office. When district offices are affected by the disaster, the state agency~~~~1~i;take other appropriate measures to supply the local agency with ffififfi.t'foffijlli~,other food, i.e. alternate food package or food instruments. "Ready-to-feed" formula will be used if the water supply is contaminated or limited.
All contracts for formula procurement by Georgia WIC and Nutrition Services will contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of a disaster.
6

3. Special Fonnula/Hospital Based Fonnula: The state agency and local agency will estimate the quantity of special fonnula and hospital based fonnula needed to sustain services until nonnal operations are restored. The state agency will then take measures to ensure that affected local agencies have supplies in the types and quantities needed. This may include state agency contracts with manufacturers, wholesalers, suppliers, retailers, and other local agencies. Procurement, shipment, and local storage of infant fonnula will be the responsibility of the State WIC Office.
4. Food Instruments: Local agencies should maintain at all times a minimum back-up supply of preprinted manual food instruments. These food instruments should be secured in such a way that they will be safe and accessible following the onset of the emergency. Based on the local agency needs, the state agency will help to sustain the local agency's inventory of food instruments.
5. Food Package: The WIC Competent Professional Authority (CPA) determines the type of food package to be issued in accordance with procedures found in the Food Package Section of the WIC Program Procedures Manual. Local agencies have the option to convert participants to the homeless food package under any of the following circumstances:
a. The participant does not have refrigeration. b. The state agency provides a means of direct distribution of WIC
foods or the local agency is able to issue food instruments and retail purchase is still viable. c. Lacks food preparation facilities such as living in a motel.
C. Certification
Depending on the duration and severity of the disaster, appropriate measures will be taken by the state agency to minimize the disruption of certification services at the local agency. When facilities, medical services, equipment, general supplies, and staff are available, the state agency will assist local agencies with maintenance of certification services. When specific facilities, medical services, or staff are needed, the state agency will enact measures to meet those needs through other local agency or state agency resources. Special provisions for expedited certifications may be authorized with approval from the
State wrc Office. Special provisions to extend certification periods when clinic does not
have adequate lab facilities -wiIII:lil~elX@\J,~(f9iJ.sid~ffi~Wl~
D. Nutrition Education Contacts
Nutrition education may be provided in group or individual setting during certification
7

and voucher issuance during this crisis situation.
Nutrition Education should address:
- food safety - meal planning - food preparation - nutrition needs of the individual - on-site education-shelters - safe water supply - general sanitation
VI. RESOURCE REOUIREMENTS
A. Staff
1. Analysis of the need caused by the disaster and monitoring and control of the response.
2. Coordination of WIC and Nutrition Volunteer staff from around the state at the site of the disaster.
3. Scheduling shifts for volunteer staff and assistance with obtaining lodging at the site of the disaster.
4. Scheduling and coordinating staff at the. State Office for the State Health Office and State WIC Office recovery efforts.
5. In coordination with local agency fInancial staff, monitoring and tracking all costs related to the disaster recovery.
B. Infant Fonnula *
1. Obtaining storage facilities near affected disaster area for storing extra supply of infant formula. Manpower to move formula from trucks to storage to shelters.
2. Procurement, shipping, storage, and method of distribution of supplies of infant formula to the disaster area.
3. Protocol of agency to contact distribution personnel (Le., helicopters, airplanes, over land all terrain trucks.)
8

C. Food Instruments 1. Obtaining supply of blank food instruments for state office remote printing. 2. Printing and shipment of pre-printed food instruments to the disaster area.
D. Transportation 1. Arranging transportation for volunteer staff. 2. Arranging transportation for local distribution of infant formula.
* Need to ship in smaller shipments over an extended period of time. Ability to change orders for
formula as need arises.
9

DATE & TIME CALL RECEIVED

STAFF AVAILABILITY FOLLOWING DISASTER

DISTRICT/UNIT CLINIC

NAME

Attachment A

PHONE DATE & TIME CAN RETURN TO WORK

COMMENTS

n

Attachment B

PAGE

DISASTER EMPLOYEE LOG

for PAY PERIOD

to

_

(beginning)

(ending)

DISASTER IDENTIFICATION/(CLINIC If):

DISTRICT:

OFFICE NAME:

CONTACT NAME:

OF
_ _

Note: Must attach completed Disaster Daily Work Activity Log for each employee listed on this form
RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS 11

4ttachment C

PAGE

OF

DISASTER DAILY WORK ACTIVITY LOG

DATE:

/

NAME: DISTRICT:

/ OFFICE:

SSN:

AM

AM

NEW ACTIVITY TIME: _~_ PM to _~_ PM

BLDG:

OTHER:.

ACTIVITY LOCATION:

Activity Description:

_

ruSE REVERSE SIDE IF NECESSARY)

AM

AM

NEW ACTIVITY TIME: _~_ PM to _~_ PM

BLDG:

ACTIVITY LOCATION: Activity Description:

OTHER:
_ _

ruSE REVERSE SIDE IF NECESSARY)

AM

AM

NEW ACTIVITY TIME: _~_ PM to _~_ PM

BLDG:

ACTIVITY LOCATION:

Description:

-'-

OTHER:
-----'Activity _

ruSE REVERSE SIDE IF NECESSARY)

SIGNATURE:

DATE:

NOTE: MUST ATTACH TO DISASTER EMPLOYEE LOG RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS

12

EMERGENCY NUMBERS

ATTACIlliENT D

CHAPTER

AMERICAN RED CROSS CONTACT

Albany Cluster I Coverage: Clay, Dougherty, Lee, Randolph, Terrell

Deborah Blanton 2421 N Slappey Blvd. Albany, GA 31701 (912) 436-4845 Fax:(912) 434-9610

Americus Cluster V Coverage: Sumter

Joan Mason P.O. Box214 Americus, GA 31709 (912) 924-2026 Fax:(912) 931-0811

Augusta Cluster II Coverage: Burke, Columbia, Glascock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro, Warren, Wilkes

Carolyn Maund 811 12th Street Augusta, GA 30901 (706) 826-4463 Fax: (706) 826-.4507

Baldwin County Cluster VI Coverage: Baldwin, Putnam, Washington, Wilkinson

Olsen Rogers P.O. Box516 Milledgeville, GA 31061 (912) 454-2675 Fax:(912} 451-5376

Bartow County Cluster VII Coverage: Bartow

Beth Kennedy 105 North Bartow Street Cartersville, GA 30120 (404) 382-0981 Fax: (404) 606-1600

Bulloch County Cluster III Coverage: Bulloch, Candler, Emanuel

Vacant P.O. Box 843 Statesboro, GA 30458 (912) 7647-4468

13

CHAPTER
'.
Fort Gordon! Dwight D. Eisenhower Army Medical Center

AMERICAN RED CROSS CONTACT
Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 (706) 791-3169/6341 After Hours: (706) 791-4517 Fax:(706) 790-4822

Fort McPherson
Fort Stewart! Winn Army Community
Hospital
Hunter Army Airfield

Kathy Staten Bldg. 536 Ft. McPherson, GA 30330 (404) 753-8315
Lynn Dowling Bldg. 8401 P.O. Box 3280 Fort Stewart, GA 31314 (912) 767-8857/2197 After Hours: (912) 7672197/8666 Fax: (912) 368-6353
Mark Stall Building 401 Hunter Army Airfield, GA 31409 (912) 352-5410 After Hours: (912) 651-5310

Mari,ne Corp Supply School
Covered by: Albany Chapter

Moody Air Force Base

JolmLukens 5124 Austin Ellipse Moody AFB, GA 31699 (912) 244-3570 Fax: (912) 333-3114

Naval Air Station Albany Covered by: Albany Chapter

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AMERICAN RED CROSS CONTACT

Georgia Low Country Cluster III Coverage: Liberty, Long, TattnalIi, Wayne
Glynn County Cluster III Coverage: Appling, Glynn, McIntosh
Gordon County Cluster VII Coverage: Gordon

Kenny Murphy P.O. Box 242 ffmesville, GA 31313 (912) 876-3975 Fax:(912) 876-3975
Beth VanDerbeck P.O. Box 1436 Brunswick, GA 31521 (912) 265-6467!l695 Fax:(912) 261-1443
Mary Thomas P.O. Box 342 Calhoun, GA 30703_0342 (706) 629-4510

Griffin Cluster VIII Coverage: Spalding
Houston-Middle Georgia Cluster VI Coverage: Bleckley, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox
Metropolitan Atlanta Cluster VIII Coverage: Fulton, DeKalb, Gwinnett, Cobb, Cherokee, Paulding, Fayette, Butts, Henry, Clayton, Douglas, itm:kdale

Brenda Hoard 100 South Hill Street Griffin, GA 30244 (404) 227-3145
Sam Register 346 Corder Warner Robbins, GA 31088 (912) 923-6332 Fax: (912) 922-8858
Martha W. Ferguson 1955 Monroe Drive, N.E. Atlanta, GA 30324 (404) 881-9800 Fax: (404) 874-2993

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AMERICAN REO CROSS CONTACT

Murray County Cluster VII Coverage: Murray

Annette Patton P.O. Box 1301 Chatsworth, GA 30705 (706) 695-7605 Fax: (706)695-7605

Newton County Cluster II Coverage: Newton

Laura Bertram 7144 Floyd Street Covington, GA 30209 (404) 786-2018 Fax: (404) 287-1236

Northeast Georgia Cluster I Coverage: Dawson, Fannin, Forsyth, Gilmer, Habersham, Hall, Lumpkin, Pickens, Rabun; Stephens, Towns, Union, White

Pamela Watts 425 Bradford Street, N.W. Gainesville, GA 30501 (404) 532-8453 (800) 282- I722 (in GA.) Fax: (404)532-8453

Rome-Floyd County Cluster VII Coverage: Chattooga, Dade, Floyd, Polk

Jean Lambert 3 I I Turner McCall Blvd. Suite A Rome, GA 31065-2733 (706) 291-6648 . Fax: (706) 235 2842

Savannah Chapter Cluster III Coverage: Bryan, Chatham, Effingham

Angela Viney 422 Habersham Street Savannah, GA 3 140 I (912) 651-5300/5310/5385 Fax: (921) 651-5329

Southeast Georgia Cluster III Coverage: Atkinson, Bacon, Brantley, Clinch, Coffee, Jeff Davis, Pierce, Telfair, Ware

Ossie Andrews 809 Isbella Street Waycross,GA 31501 (912) 283-7846/4639

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Thomas County Cluster IV Coverage: Decatur, Grady, Seminole, Thomas

AMERlCAN RED CROSS CONTACT
Gardiner Hasty P.O. Box 1135 Thomasville, GA 31799-1135 (912) 226-2181

Tift County Cluster IV Coverage: Ben Hill, Irwin, Tift, Turner, Worth
Toombs County Cluster III Coverage: Montgomery, Toombs, Treutlen, Wheeler

Maxine Franks P.O. Drawer 70770 Tifton, GA 31793 (912) 382-3133
Stan Bazemore P.O. Box 49 Lyons, GA 30436 (912) 526-3150

Troup County Cluster V Coverage: Troup
t!pson County Cluster VI Coverage: Pike, Upson
Valdosta Cluster-IV Coverage: Berrien, Brooks, Echols, Effingham, Lanier, Lowndes

Barbara Hudson 411 South Greenwood Street SuiteB laGrange, GA 30240 (706) 884-5818 Fax: (706) 882-4364
Jearme Hinson 310 North Church Street Thomaston, GA 30286 (706) 647-3023
Stephen Coyne 707 North Patterson Street Valdosta, GA 31601 (912) 242-7404 Fax:(912) 242-1553

Walker County Cluster VII Coverage: Walker

Jerry Lipps P.O. Box 372 Lafayette, Ga 30728 (706) 638-2546

CHAPTER

AMERICAN RED CROSS CONTACT

Naval Air Station Atlanta Covered by: Fort McPherson

Ranger School Covered by: Ft. Benning

Robins Air Force Basel Robins AFB Hospital

Chris Miller Family Support Center 825 9th Street Suite 109 Robins AFB, GA 31098 (912) 926-5493 After Hours: (912) 923-6332

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Walton County Cluster II Coverage: Walton
West Central Georgia Cluster V Coverage: Calhoun, Chattahoochee, Harris, Marion, Meriwether, Muscogee, Putnam, Quitman, Stewart, Talbot, Webster

AMERICAN RED CROSS CONTACT
Don Shedd 2499 Pannell Road, S. E. Monroe, GA 30655-9611 .(404) 267-3534 Fax: (404) 207-4338
Jean Kent 3940 Rosemont Drive Columbus, GA 31904 (706) 323-5614 Fax: (706) 322-2495

West Georgia Clw;ter VII Coverage: Carroll, Clay, Harralson, Randolph, Schley

Marianne Chance 401 Bradley Street Carrollton, GA 30117 (404) 832-6112

Wilkes County Cluster II Coverage: Wilkes

Sniggy Eskew P.O. Box 774 Washington, GA 30673 (706) 678-4650 Fax: (706) 678-3752

Dobbins Air Force Base Covered by: Fort McPherson

Fort BenninglMartin Army Hospital

Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706)545-5194 After Hours:(706)545-5194 Fax:(706)545-5118

Fort Gillem Covered by: Fort McPherson
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