Georgia WIC Program procedures manual fiscal year 1997 [1997]

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TABLE OF CONTENTS

I. II. III. IV. V. VI.
VII. VIII.

Page Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-I Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-I References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-I Prior Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-I Policy Memos ...................................................... IN-I Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-2 A. Introduction (IN)................................................ IN-2 B. Certification (CT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-2 C. Rights and Obligations (RO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-3 D. Administrative (AD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-3 E. Vendor (VN) ................................................... IN-4 F. Food Package (FP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-4 G. Nutrition Education (NE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-4 H. Special Population (SP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-4 I. Outreach (OR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-5 J. Food Delivery (FD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-5 K. Quality Improvement (QI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-5 L. Monitoring (MO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-6
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Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-6 A. Food and Nutrition Service (FNS!USDA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-6 B. State Agency................................................... IN-7 Addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-7 A. Local Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-7 B. State Agency ................................................... IN-12

I. PURPOSE
The purpose ofthe 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 of Human Resource (DHR) agencies, including district health units and non-DHR agencies that contract with DHR to administer and operate a WIC Program. The Georgia 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).
III. REFERENCES
This manual reflects State policies, USDA Regional instructions, and Federal regulations. It is strongly recommended that a copy of the WIC Program Federal Register (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 of such 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 staff who 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.
IN -1

VI. SECTIONS

The Georgia WIC Program Procedures Manual is divided into !Q~]P:K!~) 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 of Program Addresses (Local and State)

B. Certification (CT) Section includes:

!:!t~f:~

Eligibility Requirements

Initial Application

Processing Standards

Participant Identification

Income Eligibility
ii:,;:;;m9,9m?!?q~luimtrf4r;p;~:g~t:;~?m~

Nutritional Risk Determination

Nutritional Risk Criteria

Nutritional Risk Priority System

Changes Within A Valid Certification Period

Certification Periods

Infant Mid-Certification Nutrition Assessment

WIC Assessment/Certification Form H&lenefill

. :m~&:R!!~~~P.J~:~~~9.nit;t.:mt:ii:~~militi2a

Waiting List



Notification Requirements

Certified Waiting List

Ineligibility Procedures

VOC Cards

Transfer ofCertification

Correcting Mistakes

Georgia WIC Resource Referral Guide

IN -2

C. Rights and Obligations (RO) Section includes:
Rights and Obligations Nondiscrimination Clause Public Notification Civil Rights Fair Hearing Procedures- Participants Fair Hearing Procedures- Migrants
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D. Administrative (AD) Section includes:
Section I
Agreement with State Agency Financial Procedures Administrative Cost Categories Shared Costs Time Studies
!. P~ffiti()n.fJY;Iff{fnnetudY)\~ti:Y:fHS.
Purchasing Procedures Allocation of Funds Food Cost Projection Report Program Income
Section II
Retention of Records WIC Acronym & Logo Lobbying Restrictions
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IN- 3

E. Vendor (VN) Section includes:
:Introduction ..........
Vendor Coordinator Enrollment ofNew Vendors Vendor Stamp
Tetlliliiation .>.,;'-..>::.: : .;..>:...
y~nd~~. ~gr,~~~
y;~p:q()t:l.~~g
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7~fi:~9'Ff~!t~tl~~ggffi~~Yt~ High Risk Vendor Identification -::M.tnimmi:!~x~~2tx-S:@9:t:vtsR~~z:~i:xs~
F. Food Package (FP) Section includes:

Authorization of Foods Prescribing Foods - General Infants Children/Women with Special Dietary Needs Children 1-5 Pregnant and Breastfeeding Women Postpartum, Non-Breastfeeding Women
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G. Nutrition Education (NE) Section includes:

Purpose, Definition, Goals of Nutrition Education State Agency Nutrition Staff and Responsibilities Local Agency Staff and Responsibilities
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H. Special Population (SP) Section includes:

>Introduction

. .. ~.''-". "' . .

. ., ..

Services for Migrants

IN -4

I. Outreach (OR) Section includes:
General Information about Outreach Methods of Outreach Agencies to Contact for Outreach Public Notification Outreach During a Waiting List Program Costs
Logp
J. Food Delivery (FD) Section includes:
General Types of Vouchers Voucher Issuance - General Computer Printed Voucher Manual Vouchers Georgia WIC Program Identification (ID) Card Proxies Mailing/Delivery ofWIC Vouchers Voided Vouchers
Tf~J?Orqp:g)(ou~l!~l'
PtoratedNouchers ...:,., ,',;::<...",",',",:,:;:, :-:.,: "c,.:.:...:. Late Pick-up of Vouchers
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Establish Clinic/Clinic Changes
BorroweaNoucliers
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K. Quality Improvement (QI) Section includes:
Monitoring Participant Abuse RepaymeJit'Q:f;"~\IT<ir?RiifiliStEroceqtife
Guideli~es ti)! Investigatii1i.ID.J,ioyee Abuse
IN- 5

Procedures to Request an Employee Investigation

Vendor Compliance Investigation

Compliance Investigation Food Purchases

Disqualified Vendor/Participant Hardship

Lost/Stolen or Destroyed Vouchers

Voucher Issuance Security

NotificafioriSUfi'ifii-~;-.'- . >''

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L. Monitoring (MO) Section includes:

State Agency Monitoring Quality Assurance Self-Reviews Technical Assistance Local Agency Monitoring Tool

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VII. ADMINISTRATION A. Food and Nutrition Services (FNS)/USDA FNS/USDA administers the Program nationwide and provides grants to state health agencies. IN- 6

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 ofcounty 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.
VITI. ADDRESSES
A. Local Agencies
The following table lists all local agencies, their address, counties served, and the number of clinic sites.

DISTRICf/ADDRESS

District 1, Unit 1 (Rome)

C. Wade Sellers, M.D., M.P.H. District Health Director Gary Marcum Program Manager Rosemarie Newman District WIC Coordinator Coosa Valley Health District
NW GA Regional Hospital 1305 RedmondRoad Rome, GA 30161 (706) 295-6661/GIST 231-6661

District 1, Unit 2 (Dalton)

Joy Benson, M.D.

District Health Director

VACANT, Program Manager

Sandy Akins

District WIC Coordinator

Northwest Health District

Avenue JOO'W::Talnut "'

,.,(, --~ .., '"'-""'~., ,,.,

Suitti'#92

Deuton. GA 3012o

(706) 272-2342/GIST 234-2342

District 2 (Gainesville)

Melody A. Stancil, M.D. District Health Director David Oberhausen Deputy Program Director Jean Garner District WIC Coordinator North Health District
District Health Office P.O. Box 1295 Gainesville, GA 30503 (77Q) 535-5743/GIST 261-5743

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

#OF WIC CLINIC SITES 13

Whitfield, Murray, Gilmer, Fannin, Pickens,

7

Cherokee

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

13 '

IN -7

District 3, Unit 1 (Cobb)

Cobb, Douglas

6

Virginia Galvin, M.D. District Health Director Jack Gutkins Program Manager Beverly Demetrius District WJC Coordinator Metro West Health District (Cobb/Douglas) 1650 CouniJI Farm Road Marietta, GA 30060
('!J.f!) 514-2389

District 3, Unit 2 (Fulton)

Fulton

25

Gary Byrd, M.D. Acting Health Commissioner Eric Benning, M.D. Deputy Commissioner ofPhysical Health Paulette McCray Nutrition Services Manager Fulton County Health Department 75 Piedmont Avenue Suite #362 Atlanta, GA 30303 (404) 730-4050

District 3, Unit 3 (Clayton)

Clayton

3

Lloyd Hofer, M.D. Acting District Health Director Paula Sherrer Program Manager Kathy Thomas District WIC Coordinator Clayton CouniJI Health District 675 Forest Parkway Forest Park, Georgia 30050 (404) 363-6780

District 3, Unit 4 (Gwinnett)

Gwinnett, Rockdale, Newton

7

VACANT District Health Director E5sie Rowser Program Manager Maxine Moore District WIC Coordinator Gwinnett/Rockdale/Newton CoiDIIies District Health Office P.O.Box897 Lawrenceville, GA 30246-0897 197 Crogan Street Lawrenceville, GA 30246
f;W> 963-0754

IN- 8

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 Services Carolyn Wetzel Director East Health District Center 5380 East MounJain Street Stone MounJain, GA 30086
E,JSlf'"I;~~
Director
Central Dekalb Health Center 5475 Memorial Drive Stone MounJain, GA 30083 Contact: Marynette Casey Nyambura Adodoadji, M.D., M.P.H. Director Kirkwood Health Center 30 Warren Street AtlanJa, GA 30317 Contact: Darlene Drury, R.D., L.D.
Vicki Clark Robert V. Taylor Director North Deka/b Health Center
f::?;_5]!Jffi:Pf!t.f.l!.ifiil
Suite #/50 Chamblee, GA'JfJ..!:f.lJi4.?"~3, Contact: Carol Boe, R.D., L.D. Burretta Shepherd Director Clifton Springs Health Center 3/00 Clifton Springs Road Decatur, GA 30034 Contact: Valeria Johnson, L.D.,
Karen Turner
District 4 (LaGrange)
Lloyd Hofer, M.D. District Health Director Gus Morgan Program Manger Blanche Deloach District WIC Coordinator South Central Health District 'f?Z.Sfffl~~ (;Ordfjif{:o~aJ:pf.fll,e. !A.f:Jrt(nge;{#!!,t!i#.~/J.Z.1P {'706) 845-4035
District 5, Unit 1 {Dublin)
Grady Longino, M.D. District Health Director Jannell Knight Program Manager Wanda Foskey District WIC Coordinator South Central Health District 2121-B Bellevue Road Dublin, GA 31021 (912) 275-6545

Dekalb

8

Fayette, Heard. Henry, Butts, Carroll, Coweta. Lamar, Pike, Meriwether, Troup, Spalding, Upson

Blecldey, Dodge, Laurens, Montgomery,

10

Pulaski, Telfair, Treutlen, Wilcox, Wheeler,

Johnson

'
IN- 9

District 5, Unit 2 (Macon)
Joseph R. Swartwout, M.D. Acting, District Health Director Ollie Askew Program Manager Jacquelynn Nelson District..WIC Coordinator 8ll Hemlock Street Macon, GA 31201 (912) 751-6118
District 6 (Augusta)
Frank Rumph, M.D. District Health Director Riclunond County Health Department 1916NorthLegRoad Augusta, GA 30910 (706) 667-4250 John Nolan Program Manager Frances Wilkinson District WIC Coordinator Augusta, GA 30909 (i06) 667-4287
District 7 (Columbus)
Craig S. Lichtenwalner, M.D. District Health Director Dorothy (Dee) Cantrell Program Manager Jackie Miller District WIC Coordinator West Central Health District 2100 Comer Avenue P.O. Box 2299 Columbus, GA 31902 (706) 321-6300/FAX (706) 321-6126
District 8, Unit 1 (Valdosta)
Lynne D. Feldman, M.D. District Health Director Russell Paulk Program Manager Janet McClure District WIC Coordinator P.O. Box 5147 Valdosta, GA 31603 312 N. Patterson Street Valdosta, GA 31601 (912) 333-5290
District 8, Unit 2 (Albany)
J. Paul Newell, M.D. District Health Barbara Evans Program Manager Charlotte W. Bedell District WIC Coordinator Southwest Health District 23 I Tift Avenue Albany, GA 31701 (912) 430-4111

Hancock, Houston, Jasper, Baldwin, Bibb,

!6

Crawford, Jones, Monroe, Peach, Putnam,

Twiggs, Washington, Wilkinson

Burke, Columbia, Emanuel, Glascock,

28

Jefferson, Wilkes, Warren, Jenkins, Lincoln,

McDuffie, Richmond, Screven, Taliaferro

Harris, Talbot, Dooly, Quitman, Taylor,

23

Marion, Macon, Crisp, Sumter, Clay, Schley,

Webster, Randolph, Stewart, Muscogee,

Chattahoochee

Ben Hill, Berrien, Brooks, Cook, Echols,

12

lrwin, Tift, Turner, Lanier, Lowndes

Terrell~ Lee, Calhoun, Worth, Early,

15

Dougherty, Baker, Grady, Mitchell, Colquitt,

Miller, Thomas, Seminole, Decatur

IN -10

District 9, Unit 1 (Savannah)
Stephen King, M.D. District Health Director AlMungin Program Manager Patricia Jackson District WIC Coordinator East Health District
! 6_0?.Rl?iJi!..i!if$f!'!i.t
Savannah, GA 3J.I01 (912) 651-2571
District 9, Unit 2 (Waycross)
Ted Holloway, M.D. District Health Director Sue Scaife Program Manager Susan Horne District WIC Coordinator Southeast Health District 1101 Church Street Waycross, GA 31501 WIC Office 1718 Reynolds Street, Suite 100 Waycross, GA 31501 (912) 285-6110
District 9, Unit 3 (Brunswick)
B. Brooks Taylor, M.D. District Health Director Billy Griner Program Manager Jo Bishop Manning District WIC Coordinator Coastal Health District 1609 Newcastle Street Brunswick, GA 31521 (912) 264-3907
District 10 (Athens)
Claude A. Burnett, M.D. District Health Director John McKinley Program Manager Vickey Moody District WIC Coordinator Northeast Health District 468 North Milledge Avenue Room101-B Athens, GA 30601-3808 (706) 542-9547
Southside Healthcare, Inc.
Dwight E. Jones, M.D. Director William Osborne Program Manager Laverne Montgomery District WIC Coordinator Southside Healthcare, Inc. 1039 Ridge Avenue, S.W. Atlanta. Ga 30315 (404) 688-1350, Ext. 244

Chatham, Effingham

10

Appling, Atkinson, Bacon, JeffDavis,

23

Brantley, Ware, Bulloch, Candler, Clinch,

Charlton, Evans, Coffee, Wayne, Pierce,

Toombs, Tattnall

Bryan, Liberty, Long, Mcintosh, Camden,

16

Glynn

Barrow, Clarke, Elbert, Green, Jackson,

15

Madison, Morgan, Oconee, Walton,

Oglethorpe

Portions ofFulton ad Dekalb Counties '
IN -11

Grady Maternal & Infant Care Project

All

3

Joseph E. Taylor
Director
LiSa:StilliiW1 chief''Niitriti~nist Maternal & Infant Care Project
Grady Memorial Hospital
80 Butler Street, #1513-E
Atlanta, GA 30335 (404) 6166!4~

B. State Agency

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 of Human 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 -12

TABLE OF CONTENTS

Page

I. II.
III. IV.
V. VI.
VII. VIII.
IX. X.

General .......... -: ................................................. c:r-1
Eligibility Requirements ............................................... CT-1 A. Category ........................................................ CT-1 B. Residency ....................................................... CT-2 C. Income ......................................................... CT-2 D. Nutritional Risk .................................................. CT-2 Initial Application .................................................... CT-2
Processing Standards ............ : .................................... c:r-4
A. Timeframes ...................................................... CT-4 B. Walk-In Clinics ................................................... CT-4 C. Request for Extension .............................................. CT-4 Participant Identification .............................................. CT-5 Income Eligibility .................................................... CT-5 A. Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CT-5 B. Proxies ......................................................... CT-6 C. Adjunctive (Automatic) Eligibility .................................... CT-6 D. Definition oflncome ............................................... CT-8 E. Computing Income ................................................ CT-8 F. Verification oflncome ............................................ CI-15 Income Eligibility For Pregnant Women ................................. CI-16 Nutritional Risk Determination ........................................ CI-17 A. Required Data ................................................... CI-17 B. Referral Data .................................................... CI-17 C. Medical Data Date ............................................... CI-18 Nutritional Risk Criteria .............................................. CI-19 Nutritional Risk Priority System ...................................... :GI-19 A. General ........................................................ CI-19 B. Special Considerations ............................................ CI-20 C. Specific ........................................................ CI-20 D. Assignment ..................................................... CI-21

XI. XII. XIII. XIV. XV. XVI. XVII.
XVIII.
XIX.

Page Changes Within a Valid Certification Period .............................. CI-21 A. Women Who Ce~e Breastfeeding ................................... CI-21 B. Upgrading a Priority .............................................. CI-21 Certification Periods ................................................. CI-22 Infant Mid-Certification Nutrition Assessment ............................ CI-22 WIC Assessment/Certification Form- General ............................ CI-23 A. State WIC Assessment/Certification Form ............................. CI-23 B. Local Agency WIC Assessment/Certification Form ..................... CI-23 WIC Assessment/Certification Form- Completion ......................... CI-23 A. Front .......................................................... CI-24 B. Reverse Side .................................................... CI-25 Waiting List ....................................................... CI-26 A. Procedures for Maintaining a Waiting List ............................. CI-27 B. Procedures for Removal from the Waiting List ......................... CI-29 Notification Requirements ............................................ CI-29 A. Waiting List .................................................... CI-29 B. Disqualification .................................................. CI-29 C. Expiration of Certification Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CI-30 D. Ineligibility ..................................................... CI-30 E. Processing Timeframes ............................................ CI-30 F. Right to a Fair Hearing ............................................ CI-30 G. Right to Complain About Vendors ................................... CI-30 H. Program Explanation ............................................. CI-30 I. Referrals ....................................................... CI-31
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Certified Waiting List ................................................ CI-31 Ineligibility Procedures ............................................... CI-31 A. Ineligible Applicants Without Health Records .......................... CI-32 B. Ineligible Applicants With Health Records ............................ CI-32

Page XX. Verification of Certification (VOC) Cards ................................ CI-33
A. VOC Card Definition ............................................. CI-33 B. Required Data ................................................... CI-33 C. Orders ......................................................... CI-33 D. Inventories ..................................................... CI-34 E. Issuance ........................................................ CI-34 F. Security ........................................................ CI-34 G. Lost/Stolen/Misplaced VOC Cards .................................. CI-35 H. Instructions for Use ............................................... CI-35 XXI. Transfer of Certification .............................................. CI-36 A. VOC Card ...................................................... CI-36 B. Phone Call ...................................................... CI-36 C. Georgia WIC I.D. Card ............................................ CI-37 D. Certification Record .............................................. CI-37 XXII. Correcting Mistakes ................................................. CI-37 XXIII. Georgia WIC Resource Referral Guide .................................. CI-38 Attachments: CT-1 WIC Assessment/Certification Form- Women ............................ CI-39 CT-2 WIC Assessment/Certification Form- Infants ............................. CI-41 CT-3 WIC Assessment/Certification Form- Children ........................... CI-43 CT-4 Signed Statement oflncome ........................................... CI-45 CT-5 Verification ofincome Form .......................................... CI-46 CT-6 Data and Documentation Required for WIC Assessment/Certification - Women ..................................... CI-47 CT-7 Data and Documentation Required for WIC Assessment/Certification - Infants ...................................... CI-48 CT-8 Data and Documentation Required for WIC Assessment/Certification - Children ..................................... C' I-49 CT-9 Nutritional Risk Criteria - Pregnant Women .............................. CI-50 CT-10 Nutritional Risk Criteria- Breastfeeding Women .......................... CI-55 CT-11 Nutritional Risk Criteria- Postpartum, Non-Breastfeeding Women ............ CI-59 CT-12 Nutritional Risk Criteria- Infants ....................................... CI-62

Page CT-13 Nutritional Risk Criteria - Children ..................................... CI-66 CT-14 Notice ofTerminationf.Ineligibility!Waiting List Form ...................... CI-69 CT-15 Verification of Certification (VOC) Card ................................. CI-70 CT-16 VOC Card Inventory Log (Clinic) ...................................... CI-71 CT-17' VOC Card Inventory Log (Local Agency) ................................ CI-72 CT-18 Measuring Length/Height/Weight ...................................... CI-73 CT-19 Equipment Maintenance .............................................. CI-77 CT-20 Instructions for Use of Prenatal Weight Grid,
Prenatal Weight Gain Grids (Form #3059) ................................ CI-87 CT-21 Dietary Assessment ................................................. CI-90 CT-22 Instructions for Use ofthe Gro'Wth Charts/Growth Charts .................... CI-91 CT-23 Weight for Height Table For Determining WIC Eligibility .................. CI-109 CT-24 Physical Signs Indicative or Suggestive of Malnutrition .................... CI-110 CT-25 Recommended Daily Servings Chart ................................... CI-112 CT-26 Inappropriate Food Practices ......................................... CI-113 CT-27 Georgia Subsidized Child Care Programs ............................... CI-115 CT-28 Georgia WIC Program Referral Form .................................. CI-116 CT-29 Nutritional Risk Priority System ...................................... CI-117
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GA WIC PROCEDURES MANUAL FY '97
I. GENERAL
Certification is the process whereby an individual is evaluated to determine eligibility for the WIC Program. All persons wishing to participate in the 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 of their eligibility at the time eligibility is determined. A participant shall be issued vouchers at the time they are notified of their eligibility. The person may continue to participate in the Program until the end ofthe certification period or the end of categorical eligibility, whichever occurs first, as long as the person complies with Program rules and regulations. If ineligible, the individual is properly notified and is not placed on the Program (See CT-XIX, 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.
II. ELIGIBILITY REQUIREMENTS
The local agency may not establish any eligibility criteria for Program participation other than those established by the State agency.
To be eligible and certified for Program participation, an individual must meet all of the following requirements:
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 (I) 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 CT-XIX,
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GA WIC PROCEDURES MANUAL FY '97
Ineligibility Procedures). (Refer to CT-XI) Women Who Cease Breastfeeding, for
procedures regardi. ng 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 of residence, 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 WIC purposes.
Homeless refers to a woman infant or child who lack regular or primary nighttime residence, or whose residence is: A public or privately operated shelter designated as temporary living and/or sleeping accommodation (including a welfare hotel, shelter for domestic violence victims); a temporary accommodation in the residence of another person; an institution that provides temporary residence for individuals 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 unless there is a break in enrollment. A break in enrollment is defmed as missing a certification appointment after the current
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GA WIC PROCEDURES MANUAL FY '97
certification 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 1-6 as long as it is implemented in a consistent manner. Suggested methods ofdocumentation include, but are not limited to, a personal visit log, the WIC Certification/Assessment Form (Attachments CT-1, 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 CT-XIX, 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 CT-XIX, Ineligibility Procedures).
E. Employees must never certify 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
this application aJ:i(l:Jiotifytp~ WU:;:Q09f@l!\19f. Ifthis is not possible, arrangements must
be made to transfer appiicant/pi:irtidpant 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.
F. Special provisions should be made for scheduling Employed, Rural and Migrant participants. In the event, normal working hours are not convenient, early morning or late clinics should be held for scheduling appointments. Note: If the clinic is unable to have early or late clinics, the participants must be scheduled specific appointment times to meet federal/state requirements.
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GA WIC PROCEDURES MANUAL FY '97
G. Each local agency shall attempt:)~t){@$t']Qf:l~5po1JtJctJ()t[a pregnant woman who misses
her first appointm~nt to apply f6;''p;rt'ieip~tiSn'"ifilli~p;ogram. In order to reschedule
the appointment, the local agency must have on file an address and telephone number where the pregnant woman can be reached. Documentation of the contact (s) must be noted in the client's record.
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 ofmigrant farmworker families will be notified of their eligibility or ineligibility within ten (10) calendar days oftheir initial contact date for Program benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days oftheir initial contact date for 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 (1 0) to fifteen (15)
days to local agencies experiencing difficulty in meeting processing standards. Those local agencies in need ofan 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 tu:
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 '97
V. PARTICIPANT IDENTIFICATION
Clinic staffwill verify an applicant/participant's identification during each certification visit. The following are acceptable forms of identification: valid driver's license, immunization record, Medicaid card, Social Security card, or birth certificate. A Georgia \VIC ID 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 ifapproved 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 \VIC income guidelines 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 \VIC Program applicants/participants.
1. Pre-screening 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. Pre-screening 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 staff's initials. This should be kept in log form. 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. Determining Family Size/Income Eligibility. Family size must be determined. (See Income Eligibility for Pregnant Women VII) Then, the income for that falnily must be calculated and compared to the maximum income allowed for that family size (see Attachment 34). Income eligibility should be determined before nutritional risk eligibility, whenever possible.
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GA WIC PROCEDURES MANUAL FY '97
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 ofthe 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 of Medicaid or members of families in which a pregnant woman or
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GA WIC PROCEDURES MANUAL FY '97 infant receives Medicaid. This includes Presumptive Eligible Medicaid Recipients. (Please refer to E.3 for definition of "family".)
It should be remembered that persons who are adjunctively (automatically) income eligible for WIC must still be categorically eligible and determined to be at medical/nutritional risk in order to qualifyfor the Program. Acceptable Proof of Eligibility
If a WIC applicant presents acceptable proofofenrollment 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 applicatjon for WIC.
1. 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-XV-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 oflife. 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 ~etter of eligibility. However. this letter cannot be used as proof of eligibility for WIC because this letter does not indicate an expiration 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 (ID) Card with valid Food Stamp Number and expiration date.
NOTE:
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GA WIC PROCEDURES MANUAL FY '97
4. Verification of income is only necessary as outlined on CT-VI.F.
5. Ifthe applicant does not have proof ofenrollment in Medicaid or Food Stamps, you must determine income eligibility using actual income.
, D. Definition of Income
Income is defined as gross cash income before deductions for income taxes, employee's social security taxes, insurance premiums, bonds, etc.
E. Computing Income
1. Current vs. Annual. Clinic staff, in determining 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 of Family/Economic Unit
Family means a group ofrelated or non-related 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.
If an ad~lescent (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 ofthe
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GA WIC PROCEDURES MANUAL FY '97
parent, guardian, or caretaker with whom the child lives, with the exception of the foster -~hild (See [b]). For example, an abandoned child being cared for by a grandparent would be counted in the family size/household of the grandparent.
b. Foster Child. Ifthe 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 (I). 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 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. Pregnant women should be counted as one (1) in determining family size. A pregnant woman who does not meet income eligibility requirements on the basis of her current family size shall be reassessed for eligibility based on a family size increased by one (1) or the number of expected infant(s). (See CTVII Income Eligibility for Pregnant Women).
f. Absent Spouse (excluding military families. See [BX:J:~;g}if). 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 inclusiop. of the spouse. Only income received by the household would be used to determine eligibility.
g. Students
(1) College students who maintain a separate residence at school but who are supported by parents/guardians must be counted in the household of the parent/guardian. Students who maintain a separate residence and are self-supported must be counted as a separate household. Any regular cash supplements received from parents or guardians must be included in the student's total income.
(2) If a student receives financial assistance from any program funded under Title IV (e.g. the Pell Grant, Supplemental Educational Opportunity Grant, Byrd Scholarship, Student Incentive Grant, National Direct Student Loan, PLUS, College Work Study, etc.) the following guidelines must be followed:
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GA WIC PROCEDURES MANUAL FY '97
The portion of federally-funded student aid that is used by the ~ student for books, materials, tuition, fees, supplies, and
transportation will not be counted as income. Any portion of the aid that is used for room and board or dependent care costs will be counted as income.
h. Aliens/Foreign Students. It is legal for an alien/foreign student and his or her family to receive WIC benefits. Neither 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 information may incidentally become known during the eligibility determination process, e.g. in connection with inquiries regarding sources of family 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. Militazy Families
1. Military personnel serving overseas or assigned to a military base are considered to be members of the family and their income should be included when determining family income.
2. If children are in the temporary care ofothers while their parent is assigned elsewhere or if the child(ren) and one parent temporarily move in with friends or relatives, choose one of the following options:
(1) Count absent parents and exclude current caregivers. (2) Count children as separate economic unit. The children are considered
as having their own source of income (e.g., child allotments). When using this method, Districts must decide whether the income is adequate to sustain the children. If the children's income allotments are not adequate, then option 1 or 3 should be used. (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 of divorce, may not be considered part ofthe WIC applicant's family. A WIC applicant may count in his/her family size, a child family
CT -10

GA WIC PROCEDURES MANUAL FY '97 member who resides in a school or institution if the child's support is paid for by the WI~C applicant's family.
4. Income Inclusions
a. Monetary compensation for services, including wages, salary, commissions, or fees;
b. Net income from fann and non-fann self employment;
c. Social Security benefits and/or Supplemental Security Income (SSI);
d. Dividends or interest on savings or bonds, income from estates or trusts, or net rental income;
e. Public assistance or welfare payments;
f. Unemployment compensation;
g. Government civilian employee or military retirement, pensions, or veterans' payments;
h. Private pensions or annuities;
I. Alimony or child support payments;
J. Regular contributions from persons not living in the household;
k. Net royalties;
1. Other cash income. 1bis 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 of value which is not provided in the form of cash;
b. Income or benefits received under any federal program which are excluded from consideration as income by any legislative prohibition. These include, but are not limited to:
(1) National School Lunch Act and the School Breakfast Program
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GA WIC PROCEDURES MANUAL FY '97
(2) The Food Stamp Act of 1977 (3) JQb 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 (1 0) Military Housing (11) Title IV student financial assistance (see CT-VI.E.3.g.).
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) of Social 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-27 list the "non payment" child car~ 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. Unemployment. Applicants from families with adult members who are unemployed shall be eligible based on income during the period of unemployment if the loss of 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. If a woman is on extended maternity leave [greater than six (6) months], it may be more appropriate to use current income to determine eligibility.
7. Self-Employment. In families 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
CT -12

GA WIC PROCEDURES MANUAL FY '97
guidelines:
Net income for self-employment is figured by subtracting operating expenses from gross receipts. Gross receipts include the total value of goods sold or service rendered by the business. Operating expenses include, but are not limited to, the cost of goods purchased; rent; heat; utilities; depreciation; wages and salaries paid; and business taxes (not personal Federal, State, or local income taxes). The value of salable service and merchandise used by the family of self-employed persons is not to be included as an operating expense.
Net income for self-employed farmers is figured by subtracting the farmer's operating expenses from the gross receipts. Gross receipts include, but are not limited to, the value of all products sold; money received from the rental of farm land, buildings or equipment to others; and incidental receipts from the sale of items such as wood, sand, or gravel. A farmer's operating expenses include, but are not limited to, the cost of feed, fertilizer, seed and other farming supplies; cash wages paid to farmhands; depreciation; cash rent; interest on farm mortgages; farm building repairs; and farm taxes (but not State and Federal income taxes). The value of fuel, food, or other farm products consumed by the family is not included as an operating expense.
NOTE: For 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 ofthese 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 ofthe self-employed member. If the self-employed person's income is negative it should be listed as zero (0).
8. Migrant Farmworkers. Income eligibility is valid for in stream 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 in stream 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 redetermined, 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.
CT-13

GA WIC PROCEDURES MANUAL FY '97 Reimbursement payment represents money received for loss of assets or injuries tQ real or personal property. Reimbursement lump sum payment(s) SHOULD NOT be counted as income for WIC eligibility purposes. Examples include but are not limited to insurance reimbursement, payment on specified household expenses or medical expenses. New Money is money received as gifts, inheritances, lottery winnings, workman's compensation for lost wages or severance pay. Lump sum payments that represent new money intended to be used as income should be considered as "Other Cash Income."
The lump sum payment must not be counted for one month current income. Rather, the sum payment should be counted as annual income, or be divided by 12 to estimate a monthly income. Some lump sum payments may not be easily classified into either of the two categories, reimbursement or new money; but may represent both. In such instance treat the lump sum payment in a way that most accurately reflects the economic situation of the household. Examples of such payment include legal or medical settlement that provide reimbursement for lost property and medical expenses as well as compensation for physical or mental injury.
i!.E.~JTI9:0f~@!f!?o~p~~!:!P~:~~:!!5.h~~fi'~f!~H1il.~!!2~(~!!~!:fH~~ t&;mst#~~~m1~'i~@~i.siP~t':l~
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GA WIC PROCEDURES MANUAL FY '97
such.Circilirisrances:
F. Verification oflncome
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) of the follovving 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.
Pr~cedures for Verification. When a participant's income must be verified, a Verification oflncome Form (Attachment CT-5) must be completed. Instructions for Completing the Verification of Income Form:
I. 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 verifi~ation information by (30 days from the date ofthe 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
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GA WIC PROCEDURES MANUAL FY '97
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. If the 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 allactions taken when verifying income must be documented in the medical record. Thi~ procedure must be consistently implemented throughout each local agency.
VII. INCOME ELIGIBILITY FOR PREGNANT WOMEN
Public Law 103-438, the Healthy Meals for Healthy Americans Act provides new regulations for conducting WIC Program income assessment/determination of pregnant women. According to this law, a pregnant woman who does not meet income eligibility requirements for the WIC program on the basis of her current family size shall be reassessed for eligibility based on a family size increased by (one or) the number of expected infant(s). In keeping with current policy, confirmation of multiple gestations must be received verbally or via a written diagnosis from a physician or health professional acting under standing orders of a physician and documented in the participant's health
record.~~~~~~~~~t~li ~r&iJ[[~i~~R
The use/implementation ofthis policy must not conflict with cultural, personal or religious beliefs of the individuals.
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GA WIC PROCEDURES MANUAL FY '97

VIII.

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 (length/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. blood work, 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-6 lists the required assessment data and documentation requirements for all women, by category. This data must be collected and documented for each assessment. Required medical data used to determine the eligibility of pregnant women must be taken during the current pregnancy. 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.

If 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 each assessment.

3. Children. Attachment CT-8lists 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

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GA WIC PROCEDURES MANUAL FY '97
not on staff at the clinic. Referral data must then be evaluated by a CPA or staff at the clinic. Local ~gencies 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 of Nutrition 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. Hematocrit/Hemoglobin d. Date measurements were taken
III. Referral Agency Information a. Signature and Title of Health 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 referraldata!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
Medical data required for certification (length/height, weight, and hematocrit/hemoglobin) 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 hematocrit/hemoglobin) even if the applicant/participant's eligibility is based on other criteria.
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GA WIC PROCEDURES MANUAL FY '97
IX. NUTRITIONAL RISK CRITERIA
Nutritional risk criteriJl 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 t:ndanger health, or conditions that predispose persons to inadequate nutritional patterns or nutritionally related conditions.
Nutritional risk criteria, risk factor codes, and priority designations usedfor Georgia WIC Program certification are listed in Attachments CT-9, CT-10, CT-11, 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 applicable nutritional risk criteria. Refer to CT-XIV for information regarding the completion of the WIC Assessment/Certification Form.
X. 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:
1. Priority I: Pregnant women, breastfeeding women, and infants at nutritional need. This need is determined by measuring height/weight, 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 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.
3. Priority III: 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.
4. Priority IV: Pregnant women, breastfeeding women, and infants with a nutritional need because of poor diet or homeless/migrancy status.
5. Priority V: Children at nutritional need because ofpoor diet or homeless/migrancy status.
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GA WIC PROCEDURES MANUAL FY '97

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

' B. Special Considerations

1. Reciprocal Risk. A breastfeeding mother and her infant shall be placed in the highest priority for which either is qualified. Breastfeeding is defmed as .the feeding of breastmilk to an infant at least once every 24 hours, on the average. Even ifan infant is receiving a food package with the maximum amount offormula (i.e., 31 cans of infant formula), both the mother and infant are classified as breastfeeding if they fit the above definition.

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

3. Poswartum. Non-Breastfeeding Women

Priority III: Priority VI:

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

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GA WIC PROCEDURES MANUAL FY '97

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.

XI. 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 (S~:aTf~., 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. If no nutritional risks are evident, new certification information must be collected to determine if the 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).

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).

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GA WIC PROCEDURES MANUAL FY '97
XII. CERTIFICATION PERIODS
Certification periods are:
Pregnant Women: for the duration of their pregnancy and for up to six (6) weeks ' postpartum. There is no extension granted beyond the six (6) week postpartum cutoff.
Breastfeeding Women: for six (6) months from the date of certification and ending when the breast-fed infant turns one (1) year of age or when breastfeeding is discontinued, whichever comes first.
Postpartum. 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 ofcertification.
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 of the month, eligibility is extended to the end of the month. (See FD-ITI.E.)
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.
XIII. INFANT MID-CERTIFICATION NUTRITION ASSESSMENT
Infants certified prior to six (6) months of age will be subsequently certified on their first birthday. A mid-certification nutrition assessment, by the CPA, should be completed between five (5) and seven (7) months ofage. To ensure accessibility to quality health care services, the following procedures must be in place:
I. The initial certification ofthe 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
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GA WIC PROCEDURES MANUAL FY '97

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. N~~~;::!~~~,~~'~.~!~~J:J;~g!i~.~!f*P,*'rf.[~!f!l!~,'m!'!f~n.m[~9!f;!~~!~~~m~y~.
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.

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.

XIV. 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.

XV. 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

CT-23

GA WIC PROCEDURES MANUAL FY '97

are instructions for completion:

A. Front

1. Identification Information. 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 if it has not changed. The initial contact date must be accurately documented
to ensure that processing standards are being met. Refer to CT-III. for the
definition of "initial contact date."

3. Income 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 income screening information.

taken 4. Medical Data Date. See Q;,UY."J:U;Q; for definition of required medical data. Enter

the date medical data waS

i& 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. Length/Height. Enter the length/height to the nearest eighth of an inch.

6. Weight. Enter the weight in pounds and ounces.

7. Hematocrit/Hemoglobin. Enter the hematocrit and/or the hemoglobin value(s) in the appropriate half of the 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.

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;

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GA WIC PROCEDURES MANUAL FY '97
c. at least one (1) nutritional risk criterion is checked "Yes".
Check "No" when "a" or "b" from the above list and/or all nutritional risk factors are checked "No" (see CT-XIX, Ineligibility Procedures).
10. Priority. Enter correct priority (I - VI). Refer to CT-X.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. See Section NE, Nutrition Education, for more information regarding required referrals.
a. "Enrolled In" is used when a person is already utilizing other health services and programs. [J#PmJ.).~Hf.;i~9I'~~~t9.9~t,;IillPP~f::i::~~P!sN:I?~.f!iill?~
documente&
. - ..:.:.::-::::.;... .;.:-;..:;.~~~.~~::~~:-:-:.. '
b. "Referred To" is used when a person has been given information regarding other health services and programs.
13. Today's Date. Enter the date the assessment is completed.
14. Signature/Title. Enter signature and title (Nutr., RD., L.D., R.N., M.D., etc.). An appropriate signature consists of first 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 Stamp Recipients. (See Acceptable Proof of Eligibility-Adjunctive Eligibility)
b. Medicaid Recipients. (See Acceptable Proof of Eligibility - Adjun~tive Eligibility)
c. AFDC Recipients. Complete as Medicaid recipient.
d. Participants not receiving Food Stamps. Medicaid. or AFDC. Complete according to CT-VI (E).
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GA WIC PROCEDURES MANUAL FY '97
4. StaffSignature(s). The staffmember(s) collecting the income/residence!ID data must enter tlieir signature(s) bi1.~~1f;UJ,;e !!!!~~~1.':i;f<?:f.1IiiYJl{i[igms!~ An
appropriate signature consists offirstand lastnameo:r fiist initial, l'fP44f.1"jiii,ijJU and ... ::::~---.:::-.......:::: :
last name. Ifthe person who collects the income information is different from the
p~~eIrislolfn:Pd.~e~t~e-rimpai;nItins:g;rr$eisgnidateunrec,y eacli ofexplaitifii:ti]~t:b ...e~i1g9t~lt.~:~f~f.igrit:f<Q~pphltf~"~:a:J:i::O;.:A;;$;:f~i-l@'<:J:,s-W:Jpl:ilrttiiC~i~p~af,i~i~:
parent!gUardian/caretaker, or proxy must be asked to read (or have read to them if they are unable to read) and sign the following statement each time they are certified:
I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided is correct, to the best of my knowledge. The income I have given is my total gross household income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or
itiijiiiilll~
Due to the content of this 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 staff person 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.
XVI. WAITING LIST
A waiting list is intended to facilitate the placement of the highest priority persons at the earliest opportunity when demand exceeds available fimds. 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 record keeping requirements. The State
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GA WIC PROCEDURES MANUAL FY '97
agency requires waiting lists to be retained for a period of one (I) year plus the current year.
Local agencies must establish a waiting list in the following situations when:
1. 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. Prpcedures for Maintaining a Waiting List
I. A waiting list shall be maintained ofindividuals 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 of their 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 Termination/Ineligibility/Waiting List Form (see Attachment CTI4).
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GA WIC PROCEDURES MANUAL FY '97
Procedures for Completing the Notice of Termination/Ineligibility/ Waiting List Form: ~

a. Complete the participant's name and date, address and date of birth at the top of the form.
b. Sign the form and have the participant/parent/proxy sign the form. c. Complete the information at the bottom of the form regarding the name
and address of the WIC Program. The Fair Hearing Section must be completed when using this form. If a stamp is used for this purpose, all copies must be stamped.

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 Termination/Ineligibility/Waiting 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 Termination/Ineligibility/Waiting List Form should not ~pecify the length of time (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 -Food Bank - Food Cooperatives - Churches/Synagogues Food Pantries - Salvation Army - General Assistance Funds

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GA WIC PROCEDURES MANUAL FY '97
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. If a 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.
2. After all transfers have been removed from the waiting list, persons will be removed in priority order, highest priority fust. 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.
XVII. NOTIFICATION REOIDREMENTS
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 of Termination/Ineligibility/Waiting List Form. A copy of this 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 of the 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 Termination/Ineligibility/Waiting List Form must be issued to the participant. 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.
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GA WIC PROCEDURES MANUAL FY '97
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.
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/Ineligibility/Waiting List Form on site which states the reason(s) for ineligibility. A copy ofthe 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 Termination/Ineligibility/Waiting list Form.
E. Processing Timeframes. Members of migrant farmworker households, pregnant women, and infants will be notified of their eligibility or ineligibility for the Program within ten (10) days of their initial contact date. All other applicants will be notified of eligibility within twenty (20) days of the 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. It--i--s----':---t-ne---:-r--e--s----~2,l.w_.;i..-b.....i....l....i...~T.......o"..:-r..-t_h___e_,_!,_:,:_.,.,.,ei___f___r__t,.i.c..rP~:a--n-t-lf;O:':~~e-~am-~'~---~rl:L-,-.":"""''-'"-"7J'L~~
CT-30

GA WIC PROCEDURES MANUAL FY '97
I. 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 of the types of health services available, where they are located, how they may be obtained, and why they may be helpful.
;E Irlferin.YiiicolheCHafige. Reassessment of Income Eligibility - The local agencies may
disqu;H:fy a.Il. il1&vidual at any time during a Certification Period, on the basis of a
reassessment of program eligibility status if the individual is determined ineligible. Reassessment of a participant's income eligibility status is not mandated but must be done if there is reason to believe a participant's income status has changed (e.g. iaid off workers being rehired, participant's winning a judgement in a lawsuit).
torwhlch :ry;ID.~~y~rlfir:PaJ.-tiiparitf$!i:ijpip.:ig~ge~, a thorough re-evaluation of the programs the iD.diVfdtlai co1.lid bedetermmed adjunctively income eligible is required. If the participant does not qualify based on adjunctive eligibility, then eligibility must be determined based on income guidelines. 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.
XVTII. 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 will 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.
XIX. INELIGIBILITY 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/ ineligibility/Waiting List Form on site. (Attachment CT-14)
Procedures for Completing the Notice ofTermination/Ineligibility/Waiting List Form:
1. Fill in applicant's name and date at the top of the form including the date of birth, phone number and address.
CT- 31

GA WIC PROCEDURES MANUAL FY '97
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 will be notified of their right to request a fair hearing regarding the ineligibility determination. A copy ofthe 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 Termination/Ineligibility/Waiting List Form 3. Date the ineligibility action was taken 4. All supporting qocumentation, 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/Ineligibility/Waiting List Form must be kept in the ineligibility file. If a copy of their Notice of Termination/Ineligibility/Waiting List Form is filed in the ineligibility file, it does not also need to be filed in the health record.
CT-32

GA WIC PROCEDURES MANUAL FY '97 XX. VERIFICATION OF CERTIFICATION (VOC) CARDS
A. VOC Card Definition A VOC Card is a negotiable instrument issued to or received by participants who are transferring from one city/state to another.
B. Required Data When a VOC card (Attachment CT-15) is issued to a participant, at a minimum, the card must contain the following information: 1. Participant's name 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 ID # 9. Participant's date ofbirth 10. EDC date (if applicable)
C. Orders 91~~1~~;,p~.J:d.ete<:t~Y ~~-tlii#p:p~t~~ny:p::<?ifilli~''ffit~~~t~!~9!19ft!~meli~
~~~~t~~:;~;%~~~~~eih~~~~~~2~~~~~~r~:i1I~i~i;~~i~~=,~~~~i~
eo2tgW.!t9tni~t~.Sti~itif'Y9q~p~CJtf:\~~!~J;l!.:C~~~-~Wt9hffi~*!.~'I'i~QJ:~g:~1\~ p;~q::::&~~:\(4.!!#.?Pf9eilt~:9t~~!J.i '~~;J:\\fq:'ft>.B!i~"!t;l.~~,p~:2Pfii~~!.~g;;:!@~~:~~
!~~~4~4A~2:.W."i~~te . ~9.Q.fffce_:*r~~;~gf.~~~-~,b~lgtt:':'~9:Ifg~t~:12Y'\~;1!~P:!S!
rt9ffi~y_:!!ffi9:w~~th~~~foffii~:ttaY~t2e.:ii,.t.s~W~@m'E
CT- 33

GA WIC PROCEDURES MANUAL FY '97

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 all local 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 P.!~~by local agencies and clinics. The physical inventory must be documented on the State VOC Card Inventory Log. One staff person must conduct the inv~ntory and a second staff member must verify by signing their initials on the inventory. Both staff members must initial the log. (i.e. "Physical Inventory Conducted" with the date and initial of one (1) clerical staff and one (1) ~~g'g[:~~:m!P.1~~~).

E. Issuance

A record of the issuance of each card must be maintained. When a VOC card is issued to a participant in the clinic, the following must be recorded on the inventory log: (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. Name/City/State Participant is moving to. 8. Number of cards on hand column

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 numbers issued

3. Number of current cards on hand column

4. Number of cards received from State

5. Name oft!Y;[4,Ji~.!!!~11!!@.~

6. Date



7. Initials o~,~IJ.ffl~n~~!t~ffi~i~~~~!!I!Rr~

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

CT-34

GA WIC PROCEDURES MANUAL FY '97

VOC cards/invenfory log. These authorized personnel are determined by the local agency.

G. Lost/Stolen/Misplaced 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 of the Card.

When five (5) or more VOC Cards are lost, stolen or misplaced, the Notification Summary ofMissing VouchersNOC Card Form must be completed. (see QI Section). Once this report is received, an investigation will be conducted by the Office of Fraud and Abuse and Notification of lost VOC Cards must be reported to USDA and States in the Southeast Region will also be notified.

H. Instructions for Use

Clinic staffmust:

1. It;[9.PP.Iru!:~=J?.~i~~!!A~fffttf!f~rmQx~;~;-~!19'@q-;;~<It!~~81i~tW:Hi
All migrant farmworkers are to be. issued voc cards. ~f m~~g~!!-t''!~iJB~~
ri:ioViriwTfdUilienttffis:;oli:tliefVOCJifatdLl[f!:;.Z. :For those participants transferring ....,.,.,......... , .. .!l.::::::.:-:-:.':::<-.'::-:-:,:.:-::,<::.:''.= --"':.::::::....,,:;:,:,:;:;:;::::... .-.::.... . . ...,...... .< within the State of Georgia only, a copy of both sides of the WIC Assessment/Certification Form may be given to a participant in lieu of a VOC card. However, records must be retrievable at the initial ClinicllJ)fSffiet site.
'.'.:.....:-..:-:...:.::;:::::;.;:',. ,'...

2. Instruct the participant receiving a VOC card on its use and encourage them to

continue participation in the Program in their new location. 1\tQN:ti~lN?fR"ciiif

TefiliinatioWineli-ibiliJYlWaimrTrist~rornl"'"musr:.be':issuea~ofiiiii::::::wfi~fiwii :::;.;.::-.:-~ ;.;.;.;._.;.:,:,.;::.:=-.'-':::<:<~ .. ....;.;.;.;.;.. ;.. ::.:<..:.;:w...:.:: ...;..::.. ,g_,;:,;.:.:-::;.;:;,._.<..:..:.<O<:.

.....<.<... ..'::.::: .; ..: -:.'..;:::::...;.;...-'. .- ...;:;.::::..:..... .':::.:-:<:.'::'1::.:::.;.

~<l'9!1 :~r~ :J~]p:~~--19:.:! -:~~t:!!~P~!5\,~Ui.;i!~~;:~!~Pl!2!!:1P:!E~t!ru~!

v~s!e~~t;

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

4. Clinic staffmust place either a copy or the original VOC card in a file/record ofthe
transferring participants (i.e., migrants).

CT- 35

GA WIC PROCEDURES MANUAL FY '97 :~ &m~;m~!~2~1!~~e*.8~~f2!~!:~9i~t~l!~~~~&l2n:~:~~~,[~f{M s!:9:;;;?;:~'l't2.~:;!~.,9if@~ygg.s!9.!..~JI:o.:!~Fbest2~~~t:2m'"~!t9f~i~~~s~~
XXI. TRANSFER OF CERTIFICATION

A. VOCCard

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. 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 penalized, 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:

I. Date of the call 2. Name of the person conversed with 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 J.D. number (Georgia transfers only)

The phone call must be followed up with a request for written documentation of the

. ,., ... above from the certifying local agency/clinic. ~~1eas~~~~f!Q.R.:~(Qt:I:tl:,~}loutd.\:Q~

~~pf;J;:J!f~::s~ffi~~[,F.[ip~~

,'"::::::::..w."''''""''-'"""''_,""'.w"'

CT-36

GA WIC PROCEDURES MANUAL FY '97
C. Georgia WIC I.D.~Card
If clinic staff are unable to obtain the necessary information by phone, a valid Georgia WIC I.D. card may be accepted in lieu of a VOC card. This should be done only when immediate certification seems imperative and staff feel the I.D. 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 of the 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 I.D. 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 ofVOC cards, should report this information to the State WIC Office. When a participant(s) transfers to another District or State, a copy of the original WIC Assessment/Certification Form must be retained in the ~!!f!~!P~~ where the participant was certified.
XXII. CORRECTING MISTAKES
At minimum the following procedure must be followed when a mistake is made on an official WIC document:
1. Make a single line through the error. 2. The person who made the error places his/her initials and date near the error. 3. The correct response should be written near the line.
CT-37

GA WIC PROCEDURES MANUAL FY '97
The word "error" may~be written just above the actual error.
Correction fluid ("white-out'') may 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.
.. ~!!~~g;~~fi~M9P:,fP~~-~5Rm~~~iffi.P.ffi~;Pffi:9!~1i~P:f:i~t;~~t~~!!iiR,'~
~!'~~HSfl~ XXIII. 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 State/Federal Agency requirement that each new participant be issued this booklet, preferably at the initial certification visit which contains the income of all programs listed above. However, a participant may be given a booklet at anytime 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.
CT-38

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-1

WIC ASSESSMENT/CERTIFICATION FORM- WOMEN (FRONT)

WIC

Georgia Department of Human Resources Division of Public HeaHh

ASSESSMENT/CERTIFICATION FORM
WOMEN

CLINIC

I SITE

I WIG ID NUMBER

NAME

lAST

FIRST

II
MIOOLE INITIAl..

I BIRTHDATE

ADDRESS

CITY

I couo OORESOENCE

TELEPHONE

I SOCIAL SECURITY NUMBER

..

.,

INITIAL CONTACT DATE: DATE OF FIRST VISIT REQUESTING WIG SERVICES

(Must Chatlge date it certiflcatJOnS are no1 consecut,ve)

Cheek Each OuesttenYes or No or Wnte NIAIDI r s:ate aucdellr.esl

IS THE CLIENT INCOME ELIGIBLE?

IS THE CLIENT PREGNANT? (EfltMEDC

)

IS THE CLIENT BREASTFEEDING AN INFANT LESS THAN 1 YEAR OF AGE?

GA

W EJ GJ ETHNIC ORIGIN (check onliJ

[!Jw;

BK

SP

IN 5 AS

PRENATAL

PP or BRSTFD

ZIP CODE
ovesMIGRANT o~ BRSTFD (>o MOS.!

YES ! NO

YES

NO

YES

NO

I

I

I

-- (Enter Oelrve:y Oa:e

) (&nnwe;ght

lbs.

oz.} (Enter wkS. StSrfd)

IS THE CLIENT NON-BREASTFEEDING, LESS THAN 6 MONTHS POSTPARTUM?

!Enter Oetlverv Date

fbs.

oz.

MEDICAL DATA DATE !EnterdateheighVwcigntmsasurementwasobta;nedJ

Entt~r wks. Brstrd:

wk.$.}

Height

Weight (Enter Pr~rav:d Weight:.

lb.)

. Hematocrit/Hemoglobin (Value must be< 60days)

...

. <:t.=:,-

Cneck EaCh QuestionYes or No or Write N/A(per state gu\delines)

'>
....
;,. lb.
~ ' PRENATAL YES I NO

wks
"
lb.
~ ' PP /BRSTFD YES NO

wks.
--.. -<) _;.,,.,<

...

"'-
~ .

BRSTFD (ONLY)

YES

NO

Iron Deficiency Screening Value

(HCTiessttJan36%orHGS!esslt7an T2gms)

A

I

Below Standard We.ght fOf Hetght

(less man or ttqval to :o..J

(P-pr~t.lV'd PP-.::.,.rcm!

8

I

Above Standard Wetght tor Height

(greater ll'l.ln t~qWI to 2~..)

(P-pregr~llld, PPct..rremJ

c

I

Not FollOwing Recommended Rate of We1gl"lt Gain

(P-curtent; PPptert.JtOJI wl}

u

I

EDC or Delivel)l Date prior to 19th Birthday

G

EDC or Delivel)l Date after 35th Birthday

H

Clinical Manifestations of Malnutrition, Dental Problems, Lead Poisoning,

No Prenatal Care

I

Nutri:ionally Related Medical Conditions

J

Diabetes or Hypoglycemia

K

Gestational Hypertensive Disorders

(Ptttr~UI Only}

L

I

Multiple Fetuses or Births

(Pren~tJIIhiSIOry. PPm0!'-1 rtteentJ

M

I

EDC or Delivery Date less than 25 Months after Termination of Last Pregnancy

N

I

His:OI)I of Low Birthweight lnfant(s)

{PreMtaltl.story. PP-mcst tt/Cflflt)

1~ss th.Jn 01 tJqWJI ro 2500 gi7Jm$ rx 5 112 poundS)

0

Histol)l of lnfant(s) Gestational Age less than 38 wks (~WhiSNy, PP-mosr ream/

p

Histol)l of Fetal or Neonatal Loss

(Prenatal-hiSIOft. PPmostrecefftl

a

Greater Than 4 Pregnancies Current Use of Alcohol tEntttraz'Wir:

R

I

(Prenat~l 0"11y)

s

Regular Use of Tobacco IE"' ...-,.

I

(Prttrtat;JI Only I

T

t.;urrent Use of :;tree! Drugs

(Prtlf!iiiiAI0fllf}

u

Breastteedmg an tntant at HISK (Enter 11'\lanrs r~sk ladors

I

v

Inadequate Dielal)l Pattem

fliSUSS(!I(! by G110rg.a WIC st;Jfldards)

X

Hometessness/ Migrancy Status ELIGIBLE FOR WIG 1-'HIUHIIY: PRENATAL l lA BCOGHIJKLMNOPORSTU)

(lOJ

3

I

I

BREASTFEEDING
llJiiO!ii1CAf rrcci Ji:\J

I IABCOGHI.IKMNOPQRV) 2(V)

rono rAr:r&'l

3(Gl

IVXJ1
6 t"' 8C0!-<!I.;I(UNOPORlC3)

FOOD PACKAGE: {Specify TailOring Ins -.:lions}
SERVICES: CM (A), Heattrl Che<:k (8). Women's Uealth (0) PCM (E), PRS (F), 1mmur1 (G), I.Nd Saeet~ (H). [)enr;o HNIII'I (1), STO (J), Prwate MD (K). FOOd Stamps (L), ~od M . AFOC Nl. Mental Healtl'l 0 . NAI none OJ. AefuseO Rl. Otf'ler -SoeOI\' S\
TODAY'S DATE SIGNATURE AND TITLE OF HEALTH PROFESSIONAL

I Enrolled In I Referred To

.

.. .' '

.... :

"

-

Form 3296 {Rev. 8-95}

CT-39

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-1 cont'd

WIC ASSESSMENT/CERTIFICATION FORM- WOMEN (BACK)

INCOME DETERMINATION

'
DATE

MEDICAID CURRENT YIN

MEDICAID ID NUMBER (MUST HAVE CURRENT CARD)

FOOD STAMPS YiN (MUST SHOW PROOF)

NO. IN FAMILY

GROSS INCOME/MONTH (CURRENT OR ANNUAL)

y( )
N( )

y( )

N( )

y( )

.

N( )

y( )
N( )
y( )
N( )
y( ) N( )

CURRENT ( )
ANNUAL ( )
CURRENT ( )
ANNUAL ( )
CURRENT ( )
ANNUAL ( )

I have been advised of my nghts and obligations under the Program. I cert1fy that the mformat1on I Will prov1de, or have prov1ded 1s correct, to the best of my knowledge. The income I have given is my total gross household income (all cash income before deduction). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other health public assistance programs to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

APPLICANT SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL

(FOR USE AS DISTRICT OPTION)

TOPIC

APPOINTMENT DATE

SECONDARY NUTRITION EDUCATION

DATE OF APPOINTMENT DATE OF APPOINTMENT DATE OF

CONTACT

DATE

CONTACT

DATE

CONTACT

SIGNATURE/TITLE

WICTYPE PRENATAL OR BREASTFEEDING
EXCLUSIVELY BREASTFEEDING POST-PARTUM NONBREASTFEEDING

FOOD PACKAGES

CODE

MILK

CHEESE EGGS JUICE CEREAL DRIED PEAS/BEANS OR PEANUT BUTTER. TUNA. CARROTS

407

?gals

0

2doz Scans 3Soz

1 lb beans/peas or 18 oz peanut butter

406

Sgals

21bs

2doz Scans 3Soz

lib beans/peas or 18ozpeanut butter

"405 12 qts (lactose reduced) 31bs

2doz Scans 36oz

1 lb beans/peas or 18 oz peanut buller

404

4gals

21bs

2doz Scans 24oz

1 lb beans/peas or 18 oz peanut butter

403

4gals

lib

1 doz 4cans 24oz

1 lb beans/peas or 18 oz peanut butter

402

2gals

21bs

2doz Scans 3Soz

1 lb beans/peas or 18 oz peanut butter

401

4gals

0

1 doz 4cans 24oz

1 lb beans/peas or 18 oz peanut butter

408

?gals

11b

"504 12 qts (lactose reduced) 21b

2doz ?cans 1 doz 4cans

3Soz 24oz

1 lb beans/peas or 18 oz peanut butter, Plus an additional 1 lb. beans/peas; 4 -6 oz cans tuna & 2 lbs carrots 0

503

Sgals

0

2doz 4cans 36oz

0

502

3gals

21bs

1 doz 4cans 24oz

0

501

3gals

0

1 doz 3cans 18oz

0

Patient must have signs/symptoms or LACTOSE INTOLERANCE.documented in their medical record. See Georgia WIC Procedures Manual lor additional Food Package deterrnination,.or the Nutritional Risk Criteria Handbook.

CT-40

GA WIC PROCEDURES :MANUAL FY '97

Attachment CT-2

WIC ASSESSMENT/CERTIFICATION FORM- INFANTS (FRONT)

Georgia Department of Human Resources Division of Public Health

CLINIC

NAME

LAST

FIRST

WIC

ASSESSMENT/CERTIACATION

INFANTS

wIeDI NUMBER

II

MIOOLE INITIAL

A
11.--r-r==:;ID D
BIRTH DATE

ADDRESS

CITY

ZIP CODE

I COUNTY OF RESIDENCE TELEPHONE 0 0 0
PARENT/GUARDIAN/CARETAKER NAME:

I J SOCIAL SECURITY NUMBER

GA

ETHNIC ORGIN (check one)
(!]w-!(!]BK[!jSP~IN G) AS

l MIGRAI\.T OvES ONO

I 0 0 SEX

Male

Female

MOTHER'S BIRTHDAY:

Last Wt. Before Delivery:

Mos. Gestation at 1st Prenatal Exam:

INITIAL CONTACTOATE: DATE OF FIRST VISIT REQUESTING WIC SERVICES

MID CERT.

Check Eacr. Oues:1on Yes or No or Wnle NJA (per stale gu~lines)

YES

NO

YES NO

IS THE CLIENT INCOME ELIGIBLE?

I

MEDICAL DATA DATE (Enreraareneigtu/weJg!'Jt measuremar:r was taken)

Length Weight

(Enter birthweight

lb.

oz)

Hematocrit/Hemoglobin

(Valuemusroe~60days)

RECORD THE NUMBER OF WEEKS INFANT WAS BREASTFED (Rcundro nssrestweek, s.g. DO= Never,

"

lbs.

oz.

"

lOs.

oz

~ ~ .

8

01: 1-10days 02= 17-17days...)

wks.

wks.

Check Eacn Ouest1on Yes or No or Wnte N/A(per state guidelines)

Iron Deficiency Screening Value (Ages o-12 montf'ls: HCT. Jess ttJ.an 34";, or HGB.Jess man 11.4 grns.)

Below Standard Weight for Length (lessmanorequalro tompercenllfe)

Above Standard Weight for Length (greaterttranorequatto9Sthpercenllle)

Below Length/forAge (lessthanorequalto tOm percentile;

Not Following Established Pattern of Growth

Clinical Manifestations of Malnutrition. Dental Problems. Lead Poisoning

Nutritionally Related Medical Conditions

Low Birthweight (Jess man or equal to 2500gms. or 5 112 pounds)

Gestational Age Less Than 38 weeks (Enrer weeks gestwon

wks)

Infant of a Breastfeeding Mother at Risk (Enter mother"s riSk factors:

I

Infant (up to six months of age) of a WIC Mother or Mother with Nutritional Risk During Pregnancy

Inadequate Dietary Pattern

(assessed t:y Georgia W/Cstanearas)

Homelessness\Migrancy Status

ELIGIBLE FOR WIC

= PRIORITY: 1 (A8CEFIJOPV) 2 : (VW)

MAY UPGRADE AN INFANT'S PRIORITY;

= 4 (XV3)

NEVER DOWNGRADE

FOOD PACKAGE:(Spectly Tailonng lnstruc:u-,r.s Here)

YES
A B
c
E F
I
J 0 p
v
w
X
3

NO

YES NO

SERVICES: CH(A). Health Check(8). CMS (C)Immun (G). lead Se<een (H). Dental Heallh (1), Private
MO (K). Food S1amps CL), MediCaid (M). AFOC (N). Menial Health (0). NA/None (0), Refused (A). Otner. specify (S)
TODAY'S DATE

L Entolledln
l Referred To

SIGNATURE AND TITLE OF HEALTH PROFESSIONAL

COMMENTS: (Date\ Sign.\ Title):

(FOR USE AS DISTRICT OPTION)

TOPIC

APPOINTMENT DATE

SECONDARY NUTRITION EDUCATION

DATE OF APPOINTMENT DATE OF APPOINTMENT DATE OF

CONTACT

DATE

CONTACT

DATE

CONTACT

' SIGNATURE/TITLE

CT-41

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-2 cont'd

WIC ASSESSMENT/CERTIFICATION FORM -INFANTS (BACK)

; OATE

MEDICAID CURRENT YIN

y( ) N( )

INCOME DETERMINATION

MEDICAID ID NUMBER (MUST HAVE CURRENT CARD)

FOOO STAMPS YIN (MUST SHOW PROOF)
y( ) N( )

NO. IN FAMILY

GROSS INCOME/MONTH (CURRENT OR ANNUAL)

CUAAEilf ( ) 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 ~orrect, to the best of my knowledge. The income I have given is my total gross household income (all cash income before deduction). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information )n this.form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or Nithholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may >ubject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification nformation to other health or public assistance programs to see if my family is eligible for their services. I understand that these 3gencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CARETAKER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL

CODE
112 115 '113 116 117 118 123 126 299 216 217 221 222 223 224 225 CODE
143 193 146 196

INFANT FOOD PACKAGE CONTRACT IRON FORTIFIED STANDARD FORMULA:
ENFAMIUPROSOBEE 25 cans 32 oz ready-to-feed 25 cans 32 oz readyto-feed, 2 cans juice, 24 oz infant cereal 31 cans concentrate (Standard Manual) 31 cans concentrate, 2 cans juice, 24 oz infant cereal 31 cans concentrate, 2 cans juice 31 cans concentrate, 2 cans juice. 16 oz cereal 8 cans 16 oz powder or 9 cans 14 oz powder 8 cans 16 oz powder or 9 cans 14 oz powder. 2 cans juice. 24 oz cereal BREASTFEEDING MESSAGE 13 cans concentrate 13 cans concentrate. 2 cans juice. 24 oz infant cereal 2 cans juice, 24 oz infant cereal 1 can powder 3 cans 16 oz powder or 4 cans 14 oz powder 1 can powder, 2 cans juice, 24 oz infant cereal 3 cans 16 oz powder or 4 cans 14 oz powder. 2 cans juice. 24 oz infant cereal NON-CONTRACT SOY FORMULAS: ISOMIL, NURSOY, CARNATION ALSOY, GERBER SOY (Prescription Required) 31 cans concentrate 8 cans 16 oz powder or 9 cans 14 oz powder or 10 cans 12 oz powder 31 cans concentrate, 2 cans juice, 24 oz infant cereal 8 cans 16 oz powder or 9 cans 14 oz powder or 10 cans 12 oz powder, 2 cans juice, 24 oz infant cereal

A prescnpt1on formula toed package may be prescnbed by the Competent l-'rotess1onaiAuthonty w1th a proper order from a phySICian.
A 999 Food Package may tle tailored tly the Competent Professional Authority to meet the needs of the participant. Consult your Nutritional Risk Criteria Handbook or Georgia WIC Program Procedures Manual for a list of WIC approved formulas or additional Food Package detenminations.

CT-42

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-3

WIC ASSESSMENT/CERTIFICATION FORM- CIDLDREN (FRONT)

Georgia Department of Human Resources Division of Public Health

cLIN!
NAME

LAST

I FIRST

WIC

ASSESSMENT/CERTIFICATION

CHILDREN

WIC 10 NuMBER

II

MIDDLE INITIAL

BIRTHOATE

ADDRESS

CITY

ZIP CODE

I COUNTY OF RESIDENCE 0 0 0

TELEPHONE

PARENT/GUARDIAN/CARETAKER NAME:

GA

I SOCIAL SECURITY NUMBER

ETHNIC ORIG~check one)

I 0 [Q Wi[D BK IT] S 4 tN AS

I 0

MIGRANT
YESOr-.o

I 0 0 SEX

Male

Female

RECORD THE NUMBER OF WEEKS INFANT/CHILO SREASTFEO (RouncJ to nearest week, e.g. 00= Never. 01 = 110 clays 02 = 11-17 clays..)

Wks.

..

''> { , '''i2i#H;~;};;{:

INITIAL CONTACT DATE: DATE OF FIRST VISIT REQUESTING WIC SERVICES

(Must change date if certifications are notccnsecutNe) Check Each Question Yes Of No or Write N/A(per state guidelines) IS THE CLIENT INCOME ELIGIBLE? MEDICAL DATA DATE (EIII' d.et hlgtttligflt msur-nt tkIIJ Length/Height Weight
HematocriVHemoglobin (V~ must be 80 days/

YES -. NO

YES

NO

YES

NO

YES

NO

in.

in.

i'n.

in

lb.

lb.

lb.

lb

~ ~ ~ ~ .

.

.

.

Check Each Ouest100Yes or No Of' Write NIA(perstateguldetines)

Iron Deficiency Screening Value

(Agu 1213 monrtts: ~CT. kiss rnan 34"10 or tiGB. kiss'""" 11.4 gms)

,.:rs (A.g~s 2!5 Yts: HCT

rlln 36% or HGB '-U tfln 12 gms J

Below Standard Weight for Length (lffss m.,.., or ttQ<~<II to ICtn ~c.t'l/141

Above Standard Weight for Length (gtHr 11141n or .,qul 10 95111 preflll<l!

Below Length/Height for Age ,.,.. ,..., Qf IIQ.utl '10 10111 p.~,,~,

lA
B IC
E

Not Following Established Pattern of Growth

IF

Clinical Manifestations of Malnutrition, Dental Problems, lead Poisoning I

Nutritionally Related Medical Conditions

J

Inadequate Dietary Pattern tussl1 Oy Gotg WIC Slatultl1}

X

Possibility of Regression {NIIt ~ w~tmg ,.., ntrJ

z

Homelessness\Migrancy Status

3

ELIGIBLE FOR WIC

PRIORITY: l(ABCEFIJZ) S(XZl) FOOD PACKAGE: _,_,__,.,

YES

NO

YES

NO

YES

NO

YES

NO

I SERVICES: CH (A). Health Check (B). CMS (C) tmmun (G). Lead Screen (H). Enrolled In I Denial Hoatth 11). STO (J). Private MD (K). Food Slamps (L). Medicaid (M). AFOC
(N). Mental Heattn (0), Head Sian (P). NA/None (0), Relused (R). 01ner, specify (S) Referred To
TODAY'S DATE
SIGNATURE AND TITLE OF HEALTH PROFESSIONAL

COMMENTS: (Date\ Stgn.\ Trtle}:

Form 3285 (Rev. 895)

CT -43

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-3 cont'd

WIC ASSESSMENT/CERTIFICATION FORM- CIDLDREN (BACK)

DATE

MEDICAID CURRENT YIN
y( l N( l
yI l NI l
vI l NI l
vI l NI )

INCOME DETERMINATION

MEDICAID 10 NUMBER (MUST HAVE CURRENT CARD)

FOOD STAMPS YIN (MUST SHOW PROOF)
v( l
NI )
yI l NI l
vI l NI l
yI l NI l

NO. IN FAMILY

GROSS INCOME/MONTH (CURRENT OR ANNUAL)

CURRENT ( l ANNUAL I l
CURRENT I l ANNUAL I l
CURRENT I ) ANNUAL I l
CURRENT I ) ANNUAL I l

rhave been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided is correct, to the best of my knowledge. The income I have given is my total gross household income (all cash income before deduction). This certification form is being submitted in connection with the receipt of Federal as!!istance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other health public assistance programs to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CARETAKER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL

WICTYPE CHILDREN

FOOD PACKAGES

CODE

MILK

CHEESE EGGS

607

S_qals

0

606

4gals

21bs

sos IS ots (lactose reduced) 21bs

604

4gals

21bs

603

4gals

lib

602

2gals

21bs

2doz 2doz 2doz 2doz 2doz 2doz

601

4gals

0

I doz

600

2gals

lib

1 doz

JUICE CEREAL

Scans Scans Scans 4cans 4cans 4cans

3Soz 3Soz 24oz 24oz 24oz 24oz

4cans 4cans

24oz 18oz

DRIED PEAS/BEANS OR PEANUT BUTTER
I lb beans[J)eas or 18 oz oeanut butter I lb beans/peas or 18 oz peanut butter I lb beans/peas or 18 oz peanut butter 1 lb beans/peas or 18 oz peanut butter 1 lb beans/peas 1 lb beans/peas or 18 oz peanut butter I lb beans/peas or 18 oz peanut butter 0

Patient must have signs/symptoms of LACTOSE INTOLERANCE documented in their medical record.
A 999 Food Package may be prescribed by the Competent Professional Authority if none of the above can be tailored appropriately. See Georgia WIC Procedures Manual for additional Food Package determination, or the Nutr~ional Risk Criteria Handbook.

(FOR USE AS DISTRICT OPTION)

TOPIC

APPOINTMENT DATE

SECONDARY NUTRITION EDUCATION

DATE OF APPOINTMENT DATE OF APPOINTMENT DATE OF

CONTACT

DATE

CONTACT

DATE

CONTACT

SIGNATURE/TITLE

CT-44

GA WIC PROCEDURES MANUAL FY '97 SIGNED STATEMENT OF INCOME

Attachment CT-4

I, _ _ _ _ _ _ _ _ _ _ _ _, cannot come in to apply for WIC for my Parent/Guardian
child(ren)_ _ _ _ _ _ _ _ _ _ _ _ _. I have given permission to Name(s) ofChild(ren)
- - - - - - - - - ' - - t o file my application. The total gross income of my Proxy
family is $_ _ _ _ p e r - - - - The number of people in my family is

Parent/Guardian Signature

Date

CT-45

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-5

VERIFICATION OF INCOME FORM

INSTRUCTIONS:
Prior to verifvin~ income: Date and sign the top of the form. 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:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I. Participant's N a m e : _ - - ' - - - - - - - - - - - - - - - - - - - - - - - 2. Reason for requesting verification: - - - - - - - - - - - - - - - - - - -

Date verification requested (same as date on bottom half): - - - - - - - - - - -
Initials ofstaff requesting verification: - - - - - - - - - - - - - - - - - 3. Method ofVerification (please attach):
_ _Pay stubs _ _Employer statement (or other responsible person) _ _Most current tax return _ _On-going records (self-employed only)
Date verification received:___ Receiving staff's signature:._ _ _ _ _ _ _ _ __
4. Action t a k e n : - - - - - - - - - - - - - - - - - - - - - - - - - -

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

Date:_ _ _ _ _ Staff's 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 WIC 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)

You have thirty days from today to provide this WIC clinic with one ofthe 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 of food 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 ofAgriculture, or the Office ofAdvocacy and Enterprise, Washington, D.C. 20250.

CT-46

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-6

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

WOMEN

Documentation

Prenatal

Breastfeeding

Postpartum NonBreastfeeding

Height

Required

Required

Required

Weight

Required

Required

Required

HctorHgb

Required

Required

Required

Prenatal Weight Grid

Required

NIA

NIA

Dietary Intake/ 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, 3 As Required

G, H, I, J, K, M, N, 0, P, Q, R, V, Z, 3 As Required

G, H, I, J, K, M, N, O,P,Q,R,3 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-20 for information regarding use of the Prenatal Nutrition Assessment Form.

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

CT-47

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-7

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Documentation

Infant Certified in Hospital Prior to Initial Discharge or Neonate Qualifying
as Priority II

Infant 0-6 Months

Infant 6-12 Months

Length

Birth Data or other measurement

Required

Required

Weight

Birth Data or other measurement

Required

Required

HctorHgb

N/A

Optional

Required

Weight/Age Plotted

Optional

Required

Required

Length/Age Plotted

Optional

Required

Required

Weight/Length Plotted

Optional

Required

Required

Dietary Intake/ Summary

Optional

Required

Required

Dietary Evaluation

Optional

Required

Required

Risk Factors

I, J, 0, P, V, W, 3 As Required

I, J, 0, P, V, W, 3 As Required

I, J, 0, P, V, W, 3 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-48

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-8

DATA ANn DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

CIDLDREN

Documentation

Length or Height

Required

Weight

Required

HctorHgb

Required

Weight/Age Plotted

Required

Length or Height/Age Plotted

Required

Weight/Length or Height Plotted

Required

Dietary Intake/Summary

Required

Dietary Evaluation

Required

Risk Factors

I, J, Z, 3 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-49

GA WIC PROCEDURES MANUAL FY '97 NUTRITIONAL RISK CRITERIA

Attachment CT-9

CODE

PRIORITY

PREGNANT WOMEN

A IRON DEFICIENCY SCREENING VALUE

I

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

B BELOW STANDARD WEIGHT FOR HEIGHT

I

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 I

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

I

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)

I

Defined as: growth in fundal height less than one (1) em per week or less than three (3) em 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 EDC PRIOR TO 19TH BIRTHDAY

I

H EDC AFTER 35TH BIRTHDAY

I

CT-50

GA WIC PROCEDURES MANUAL FY '97

Attaclunent CT-9 cont'd

CODE

PRIORITY

I CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING, NO PRENATAL CARE

I

1. Classical clinical manifestations as described in Attachment CT-23. Any one 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.

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

I

Any disease or condition affecting nutritional status. As defmed by 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 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

I

d. Simple cold;

2

e. Occurrence ofpneumonia, 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 of metabolism; any medical condition that interferes with the ingestion, absorption or utilization of nutrients and requires a therapeutic diet.

CT- 51

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-9 cont'd

CODE

PRIORITY

a. Chronic diseases or medical conditions which are directly related to

nutritional status of the individual must be identitied 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

I

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

I

Document the presence ofany one (1) ofthe following in the participant's health record:

1. Pregnancy Induced Hypertension (PIH): a. Blood pressure reading in 2nd trimester of 120/80 or higher; b. Blood pressure increase of30mm Hg systolic or 15mm Hg diastolic from prepregnancy 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

I

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.

N EDC LESS THAN 25 MONTHS AFTER TERMINATION

OF LAST PREGNANCY

I

Document termination date of last pregnancy and EDC in the participant's health record.

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-9 cont'd

CODE

PRIORITY

0 HISTORY OF LOW BIRTH WEIGHT INFANT(S)

I

Woman has delivered one (1) or more infants weighing 2500 gms (5 pounds 8 ounces) or less at any time 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

I

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

Q HISTORY OF FETAL OR NEONATAL LOSS

I

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

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

R GREATER THAN FOUR (4) PREGNANCIES

I

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

S CURRENT USE OF ALCOHOL

I

Defined as any current intake of alcohol during pregnancy.

T REGULAR USE OF TOBACCO

I

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.

U CURRENT USE OF STREET DRUGS

I

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

CT-53

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-9 cont'd

CODE

PRIORITY

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 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.

3 HOMELESSNESS!MIGRANCY STATUS

IV

Homelessness and Migrancy as defmed in the Special Populations Section, WIC Procedures Manual.

CT-54

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-10

CODE

NUTRITIONAL RISK CRITERIA

PRIORITY

BREASTFEEDING WOMEN

A IRON DEFICIENCY SCREENING VALUE

I

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

B BELOW STANDARD WEIGHT FOR HEIGHT

I

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

I

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

I

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

Total weight gain of less 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 DELIVERYDATEPRIOR TO 19THBIRTHDAY

I

H DELIVERY DATE AFTER 35TH BIRTHDAY

I

I CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING, NO PRENATAL CARE

I

1. Classical clinical manifestations as described in Attachment CT-23. Any one , 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-55

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-10 cont'd

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.

I

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

J NUTRITIONALLY RELATED MEDICAL CONDITIONS

I

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 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 poirit system (approximate dates ofeach 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 of metabolism; 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.

GA WIC PROCEDURES MANUAL FY '97 CODE

Attachment CT-10 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

I

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 MULTIPLE BIRTHS

I

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

N DELIVERY DATE LESS THAN 25 MONTHS AFTER TERMINATION

OF LAST PREGNANCY

I

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

0 HISTORY OF LOW BIRTH WEIGHT INFANT(S)

I

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

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

I

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

Q IDSTORY OF FETAL OR NEONATAL LOSS

a Document date(s) offetal/neonatal 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

I

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

CT- 57

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-10 cont'd

CODE

PRIORITY

v BREASTFEEDING AN INFANT AT RISK

I, II, IV

fufant 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

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 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.

HOMELESSNESSIMIGRANCY STATUS

IV

3 Homelessness and Migrancy as defined in the Special Population Section, WIC Procedures Manual.

z POSSIBILITY OF REGRESSION IF REMOVED FROM THE PROGRAM

IV

Possibility of regression is the likelihood ofreturning 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 of the WIC Assessment/Certification Form.

Regression cannot be used for the initial certification period. Priority remains the same as most recent certification priority.

GA WIC PROCEDURES MANUAL FY '97 NUTRITIONAL RISK CRITERIA

Attachment CT-11

CODE

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 of less 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 DELIVERYDATEPRIOR TO 19TH BIRTHDAY

III

H DELIVERY DATE AFTER 35TH BIRTHDAY

VI

I CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING, NO PRENATAL CARE

VI

1. Classical clinical manifestations as described in Attachment CT-23. Any one 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 '97 CODE

Attachment CT-11 cont'd 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 NUTRITIONALLY RELATED MEDICAL CONDITIONS

VI

Any disease or condition affecting nutritional status. As defmed 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 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 ofeach 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 of metabolism; 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.

rT- llO

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-11 cont'd

CODE

PRIORITY

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

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

K DIABETES OR HYPOGLYCEMIA

VI

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 MULTIPLE BIRTHS

VI

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

N DELIVERY DATELESS THAN25 MONTHS AFTER TERMINATION

OF LAST PREGNANCY

VI

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

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

VI

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

Q HISTORY OF FETAL OR NEONATAL LOSS

VI

1. Applies to most recent pregnancy only. Does not include elective abortions. 2. Neonatal loss is defmed 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- 61

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-12

CODE

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 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.

3 HOMELESSNESSIMIGRANCY STATUS

VI

Homelessness and Migrancy as defmed in the Special Population Section, WIC Procedures Manual.

NUTRITIONAL RISK CRITERIA

INFANTS

A IRON DEFICIENCY SCREENING VALUE

I

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

B BELOW STANDARD WEIGHT FOR LENGTH

I

On NCHS B-36 month growth chart (see Attachment CT-21), weight for length plot is on or below the 1Oth percentile line.

C ABOVE STANDARD WEIGHT FOR LENGTH

I

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

E BELOW LENGTH FOR AGE

I

On the B-36 month growth chart, length for age plot is on or below the 1Oth 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.

rT _r::.?

GA WIC PROCEDURES MANUAL FY '97 CODE

Attachment CT-12 cont'd PRIORITY

F NOT FOLLOWING ESTABLISHED PATTERN OF GROWTH

I

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 oftwo (2) growth channels
at any time in the prior six (6) months.

Note: Head circumference is an important indicator 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.

I CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING

I

1. Classical clinical manifestations as described in Attachment CT-23. Any one (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

I

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 NUTRITIONALLY RELATED MEDICAL CONDITIONS

I

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 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).

Points (each)

a. Urinary tract infection;

4

b. Episode of bronchitis;

6

c. Streptococcus infection;

6

d. Simple cold;

2

CT- 63

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-12 cont'd

e. Otitis media;

4

f. Occurrence of pneumonia,

12

severe burns, major surgery,

tuberculosis, hepatitis,

meningitis, cancer.

' Examples:

(1) 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.

(2) A 3 month old infant 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 of metabolism; 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.

I

4. Infant hom to a mother presently using or with a history of street drug or alcohol use.

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

0 LOW BIRTH WEIGHT INFANT

I

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 AGE LESS THAN 38 WEEKS

I

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

CT-64

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-12 cont'd

CODE

PRIORITY

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.

w INFANT [UP TO SIX (6) MONTHS] OF A WIC MOTHER OR MOTHER

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 (1) 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.

3 HOMELESSNESSIMIGRANCY STATUS

IV

Homelessness and Migrancy as defmed in the Special Population Section, WIC Procedures Manual.

CT- 65

GA WIC PROCEDURES MANUAL FY '97 NUTRITIONAL RISK CRITERIA

Attachment CT-13

CODE

PRIORITY

CHILDREN

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 LENGTH/HEIGHT

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 Attachment CT-21).

C ABOVE STANDARD WEIGHT FOR LENGTH/HEIGHT

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 LENGTH/HEIGHT FOR AGE

III

Length/height for age plot is on or below the 1Oth 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.

r.T- 1\1\

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-13 (cont'd)

CODE

PRIORITY

4. Deviating from estab'lished 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 \VIC.

I CLINICAL MANIFESTATIONS OF MALNUTRITION, DENTAL

PROBLEMS, LEAD POISONING

III

1. Classical clinical manifestations as described in Attachment CT-23. Any one 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 NUTRITIONALLY RELATED MEDICAL CONDITIONS

III

Any disease or condition affecting nutritional status. As defmed 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 ofpneumonia, severe burns,

12

major surgery, tuberculosis, hepatitis, meningitis,

cancer.

CT- 67

GA WIC PROCEDURES MANUAL FY '97 CODE

Attachment CT-13 (cont'd) PRIORITY

3. Presence of chronic fenal disease, cardiac disease; cerebral palsy; cystic fibrosis;

thyroid disorders; inborn errors of metabolism; any medical condition that

interferes with the ingestion, absorption or utilization of nutrients 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 PATTERN

v

1. Any food group missing based on the Recommended Daily Servings 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.

Z POSSIBILITY OF REGRESSION IF REMOVED FROM THE PROGRAM

III, V

Possibility of regression 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 of the WIC Assessment/ Certification Form. Regression cannot be used for the initial certification period. Priority remains the same as most recent certification priority.

3 HOMELESSNESSIMIGRANCY STATUS

v

Homelessness and Migrancy as defmed in the Special Population Section, WIC

Procedures Manual.

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-14

NOTICE OF TERMINATIONIINELIGIDILITY/WAITING LIST FORM

i1J
D....H,..,R..
_D..E,'M..R.1.V.,E.N,T..O.,f.' .
NAME:

Ge"'\?o ~of ~\moo........,., OMsion of l'l.blic: Heol!h - WIC f'n:>ggm
NOTICE OF TERMINATION I INELIGIBILITY I WAITING LIST
IDATE:
DATE OF BIRTH:

ADDRESS, CITY/ZIP CODE'

IPHONE NUMBER:

TERMINATION / INELIGIBILITY SECTION:
0 You ore not ef~gible for the WIC Program bec:ouse you: 0 You ore being terminated from the WIC Program be<cuse you:

_ _ hove on income thot is too high for the WJC Program.

_ _ do not live in the area served by this WIC Program.

_ _ ore not pregnant. postpartum.()( bfeostfeeding 'WOI"non: child under f;..~ (5j r~or~

_ _ do not hcve a med:ccl / nutri:;Ot~ol heohh prcOlem.

_ _ dtd not return to the clinic br your recertificc!;on oppc-ir~:nrc:~; co _____ ----- _______ - - - - - - - - (dote). _ _ did not pick--t..'P yoor food ...ouche:rs for'""''<..: 121 mon:h~ Yo:.::.J wrt! be: :e~n~irOicd .:-

r
I
I

(cio:e). Other _ _ Fund ore not ovoilobJ.e to serve posrpor!'t.:m r.onbrecsrfeedi;"ls women.
--

-

SUSPENSION SECTION:

0 You ore being suspended from the WIC Program for three !3) months b~ouse )'01J b<oke the following

WIC Program rule( s)

WAITING LIST SECTION:

.. 0 You ore being placed on o waiting list Funds ore not ovoiloble to serve priority{;es)

You ore

in priority

Yo1.1 may still receive nutrit:onol education end other services prov;ded by the Health Department If you need information or would like to discuss this decision. please contact the WIC Program at the

address below:

FAIR HEARING SECTION:

You hove c right to c fcir hearing if you do not ogree with the reosoo lex your te<minctico f ine!"ogib.Toty 0< waiting
list placement A request fo< c fair hearing must be mode within 60 doys of the dote of this notice. fair hearing requests should be cddressed to:

WICPROGRAM

ADDRESS

.

CITY/ZIP CODE

/
PHONE NUMBER.

PARnCIPANT SIGNATURE/PARENT/CARETAKER/GUARDIAN

WIC REPRESENTATIVE SIGNATURE/TmE

This is an Equol Opportunity P~ram. If you bel"oeve you have been d".s<riminct..O against beccuse of nxe. color. notional origin, cge. sex <x hancf!Ccp, write immediatelY to the Secretory of Agricullure, Washington, 0. C 20250.

I.

Priority 1:

2.

Priority 2:

3.

Priority 3:

4.

Priority 4:

5.

Priori1y 5:

6.

Priority 6:

NUTRITIONAL RISK PRIORITY SYSTEM
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.
Breaslfeeding women who do not qualify under Priority I. 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 Progr.::~.m participants during pregnancy but had a nutritional need.
Children with a nutritional need. This need is derennincd by m~asuring height/weight. taking a blood test and medical history.
Postpanum teenagers who are not breastfeeding.
Pregnant women, breastfeeding women and infants with a nutritional need because of poor diet or homeiess/migrancy status.
Children w:th a nutritional need because of poor diet or hometess/migrancy status.
Postpanum. nonbreast'xecding women with a nutritional need, or homeless/migrancy status and homeless/migrant postpartum non-breastfeeding teenagers.
CT-69

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-15

VERIFICATION OF CERTIFICATION (VOC) CARD

STA1E OF GEORGIA DEPARTMENT OF HUMAN RESOURCES VER.IFICATION OF CERTIFICATION CARD

PARTICIPANT/PARENT/GUARDIAN SIGNATURE

SIGNATURE OF WIC OFFICIAL

AUIHORlZED PROXY SIGNATURE

COUNTY/CLINIC

TELEPHONE NUMBER

CLINIC ADDRESS

THIS CARD MUST BE ACCEP1ED BY ALL STA1E AND LOCAL AGENCIES AS A WIC PROGRAM VERlFICATION OF CERTIFICATION UNTIL EXPIRATION DA1E.

-------------------------------PARTICIPANT~GHTS--------------------------------
Standards for participation in the program are the same for everyone regardless ofrace, color, national origin, age, sex, or handicap.

You may appeal any decision made by the local agency regarding your participation in the Program.

The local agency will make health services and nutrition education available to you and you are encouraged to participate in these services.

------------------------------DERECHOSDEPARTICIPAN1ES--------------------------Las nonnas para Ia participaci6n en el programa son las mismas para todas las personas no importa Ia raza, color, ellugar de nacimiento, edad, sex o fisico o mental impedimenta.

Usted puede apelar Ia decision tomada porIa agencia local con respecto a su participaci6n en el Programa.

La agencia local arreglara para useted Ia disponibilidad de servicios de salud y de educaci6n en asU!ltos de nutrici6n y se recomienda que Ud. Haga uso de estos servicios.
(Front)

03265"

PARTICIPANTCERTIFICATION~ORMATION

PARTICIPANT NAME

DA1E OF BIRTH

CERTIFICATIONDA1E

DA1E CERTIFICATION EXPIRES

HEIGHT

FOOD PACKAGE

P~O~

WEIGHT EDCDA1E

LAST DA1E OF VOUCHER ISSUANCE

I.D.NUMBER DA1E OF INCOME TAKEN MEDICAL DATA DA1E NUTRITIONAL ~SK C~ HEMATOCRIT
LAST DA1E OF NUIRITION EDUCATION

FORM 3292 (Rev.I0-85)

(Back)

I""''T' '1(\

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-16

CLUUCVOCCARDINVENTORYLOG

GEORGIA WIC PROGRAM VOC CARD INVENTORY LOG

CARD NUMBERS (RECEIVED)

CARD PARTICIPANT'S NAME

NUMBERS

(PRINT)

(ISSUED)

SIGNATURE PARENT/GUARDIAN
CARETAKER

CITY STATE


WIC LD. NlJMBER

D Ciiniics._t r_i c_t '_ - -_- -_- -_-_-

NUMBER OF
CARDS ON
HAND

DATE STAFF STAFF INlTIALS INITIALS

NOTE:

A Physical Inventory ofVOC Cards must be performed by the local agency 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).
* !!E~f.J#ig~-*J~~-~~~I:'IJ~;yg,g;~~I:'C:I]:O:~!~ifi~{'W~Yi~g;J~~~~:iiiii.~-.5'\~!IM<iti~g~:~i!~~~~It@.il.~~~~~9.
!!Y.l~e:

CT -71

GA WIC PROCEDURES MANUAL FY '97
LOCAL AGENCY VOC CARD INVENTORY LOG

Attachment CT-17

CLINIC NAME
'

VOCCARD NUMBERS
ISSUED

NUMBER OF
voc
CARDS ON
HAND

NUMBER OF
voc
RECEIVED
FOR
THE STATE

NAME OF STAFF WHO ISSUED VOC CARDS

DATE

INITIALS INITIALS

(CPA)

(CPA)

CT-7?

GA WIC PROCEDURES MANUAL FY '97 MEASURING LENGTH

Attachment CT-18

~=

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

Material/Equipment:

Recumbent length board with fixed headboard and movable footboard, both at right angles Marked in increments of 118 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 of the board,

the measurer should hold the child's knees together, gently pushing them down against the board with

one (1) hand to fully extend the child. With the other hand the measurer should slide the footboard to

the child's feet until both heels touch the foot piece. Toes should be pointing directly upward.

4.

Recheck head placement. Immediately remove the child's feet from contact with the footboard with

one (1) hand, while holding the footboard securely in place with the other hand.

5.

Measure length in inches to the nearest 118 inch. Repeat the measurement by sliding footboard away

and starting again until two (2) readings agree within 114 inch.

6.

Record the second reading promptly.

CT-73

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-18 cont'd

MEASURING HEIGHT

Age:

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/Equipment:

Wall mounted or portable stadiometer or metal measuring tape mounted on wall. A right angle head board. Marked in increments of 118 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 fo~

three (3) contact points: (a) shoulders, (b) buttocks, and 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 118 inch.

6.

Repeat the adjustment of the headboard and remeasure until two (2) readings agree within 114 inch.

7.

Record the second reading promptly.

rT-7LI.

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-18 cont'd

MEASURING WEIGHT

~=
Infants and very young children up to 35 pounds Materials/Equipment:

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).

If not, use the adjustment screws to move adjustable zeroing weight until the beam is in zero (0)

balance.

2.

Remove shoes and clothes. Remove diaper if wet.

3.

Place infant/child in .center of scale (may be done sitting or lying down).

4.

Move the weight on the main beam away from the zero (0) position (left to right) until the indicator

shows excess weight, then move the weight back (right to left) towards the zero (0) position until too

little weight has been obtained.

5.

Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator

is centered and stationary. (Record weight)

6.

Repeat the measurements by moving the fractional beam until two (2) readings agree within~ ounce.

7.

Record the second reading promptly.

CT-75

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-18 cont'd

MEASURING WEIGHT

Age:

Children who can stand unattended by an adult Adults

Materials/Equipment:

Standard platform beam scale with non-detachable weights Marked in increments of at least 114 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).

If not, use adjustment screws to move the adjustable zeroing weight until the beam is in zero (0)

balance.

2.

Should be wearing minimal indoor clothing. Remove shoes, heavy clothing, belts, and heavy jewelry.

Be sure pockets are empty.

3.

Have child/adult stand in the center of the platform, arms hanging naturally. The child/adult must be

free standing.

4.

Move the weight on the main beam away from zero (0) until the indicator shows that excess weight has

been added, then move the weight back towards the zero (0) position (right to left) until just barely too

much weight has been removed.

5.

Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator

is centered.

6.

Make sure the child/adult is still not holding on, then record to the nearest 114lb.

7.

Have the child/adult step off scale and return weight to zero (0). Repeat until two (2) readings agree

within 114 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-76

GA WIC PROCEDURES MANUAL FY '97 EQUIPMENT MAINTENANCE

Attachment CT-19

A yearly calibration of scales is required for proper usage. To arrange for your equipment to be calibrated, please contract a scale company licensed by the Georgia Department ofAgriculture or each local agency/clinic may calibrate its scales by using the Procedures for Testing Scales developed by the Georgia Department of Agriculture. Refer to CT-84 - 92 for Testing Procedures and a list of licensed scale companies.

Georgia Department of Agriculture 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 ofhematological 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. SpiiU?-ing one (1) sample of blood twice:

1. 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. If the two (2) value readings are the same, the centrifuge is packing/spinning the red blood
cells sufficiently and the centrifuge is calibrated. 6. If the 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-77

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19

PROCEDURES
FOR TESTING SCALES

SOURCE: GEORGIA DEPARTMENT OF AGRICULTURE, FUELS AND MEASURES DIVISION, 1995.

CT-78

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19

PROCEDURES FOR TESTING INFANT AND ADULT SCALES AT COUNTY HEALTH CENTERS

I. EQIDPMENT
A. Medium-sized flathead screwdriver.
II. WEIGHTS
A. One 8 oz. weight B. Two 1 lb. weights C. Two 5 lb. weights D. One 25 lb. weight E. Four 50 lb. weights
Ill. PRE-TEST
A. Make sure scale is on finn surface.
If adult scale is to be used on carpeted floor, cut and place a 2'x2'x3/4" square of plywood under scale for stability.
Infant scales should be placed on a firm surface also and be free from foreign objects that might bind against the weighing deck or might slide under the scale and rub the under workings and affect the weight reading.
B.. Make sure scale is level. Some infant scales are equipped with a bubble type leveling indicator. If your scale does not have a bubble leveler, visually determine the most level position.
C. Zeroing the adult scale
I. Make sure the weighing deck is free of weighs or other objects.
2. Position all sliding poises all the way to the left and put them directly on the "0" mark or setting.
3. Using the screwdriver, turn the zero setting screw located on the left end of the weigh beam assembly.
This will raise or lower the other end of the weigh beam so a zero position can be effected; that is to say, the right end of the weigh beam is floating equal distance between the loop parameters without touching either the top or bottom of the loop.
When this condition has been accomplished, the scale is now zeroed!

CT-79

GA WIC PROCEDURES MANUAL FY '97 D. Zeroing the Infant Scale

Attachment CT-I9

I. Make sure the weighing deck is free of weights or other objects.

2. Check under the scale for papers, pens or other objects.

3. Position all sliding poises all the way to the left and put them directly on the "0" mark or setting.

4. The same procedure is used to zero infant scales except that usually a screwdriver needn't be used because most zero setting mechanisms on infant scales are adjusted by turning the zero setting screw or sliding the zero setting poise by hand. The fmal results should be that the weigh beam balances just as it would on an adult scale.

IV. TESTING THE SCALE (MECHANICAL TYPE) A. For Adult Scales

After the scale has been zeroed, place a 25 lb. weight in the center of the weighing deck. Slide the top poise to the right and stop at 25 lbs. When the poise is released, the beam should float or balance equal distance from the top and bottom of the loop on the right end of the scale. However, if this does not happen, slide the poise to the left or right until the beam balances. By doing this, you can determine the amount of error at this particular point.

Now remove the I5lb. weight and replace it with a 50 lb. weight, and slide the top poise t<> the right out to the 50 lb. mark. You have now tested the top poise to its capacity - 50 lbs.

If all is good so far, slide the top poise to the left back to the "0" mark and leave it there while you slide the bottom poise to the right tot he 50 lb. mark. If it balances, proceed to the next weight by adding another 50 lb weight to the one already on the scale. Now you have I00 lbs. of weight on the scale.

Leaving the bottom poise on the 50 lb mark, slide the top poise out to the 50 lb. mark. This totals IOO lbs. When released, it should balance. Now slide the top poise back to "0" and slide the bottom poise out to I00 lbs. This rotation procedure should be followed at 50 lb. intervals all the way up to 200 lbs. If you have more weights, you can add them on, also; but 200 lbs. should be sufficient.

B. For Infant Scales

After the scale has been zeroed, place a ~ lb. (8 oz.) weight on the scale and slide the top poise out on to the right, stopping at the 8 oz. mark.

When the poise is released, the beam should float or balance equal distance from the top and bottom of the loop on the right end of the beam.

If a pointer type balance indicator is used, the beam should point directly level with the tip of the zero indicator.

C:T- RO

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19 cont'd

Now remove the 8 oz. weight and replace it with a 1 lb. mark. This has tested the top poise to its capacity, lib. Now remover the lib. weight. Replace it with the 8 oz. weight again, and slide the top poise back to The 8 oz mark. Now place 5 lbs. on the weighing deck along with the 8 oz. weight and slide the bottom poise to the right to the 5 lb. mark. By moving the top poise to the left or right of the 8 oz. mark, you can determine the error.

Now add 5 more lbs. for a total of 10 lbs. 8 oz. If your scale balances, proceed further.

Remove the two 5 lb. weights and place the 25 lb. weight, for a total of 25 lbs. 8 oz. by moving the top poise to the left or right of the 8 oz. mark, you can determine the error. By adding back the two 5lb. weights, you can check your infant scale at 35lbs. 8 oz.

V. TESTING THE SCALE (ELECTRONIC TYPE)

A. For Infant and Adult Scales

Zeroing an electronic scale is accomplished by pressing the "zero" key or button varies depending on make and model.

Make sure all objects are away from the scale and nothing is under the scale and nothing is on the weighing deck. Then press the zero ('0") button, hold for a few seconds, then release. All numbers on the digital display should then read "0". If the scale will not read all zeros, a maintenance or service call should be made by a scale service company. If the scale does zero, then proceed.

Starting with the smallest denomination weight available ( an 8 oz. weight for infant scales and a 25 lb. weight for adult scales) , place weights on the weighing deck in increasing numbers in order to build up weights equivalent to the capacity of the scale, or in the case of an adult scale, build up weights as high as possible.

CT- 81

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19 cont'd

LIST OF LICENSED SCALE MECHANICS

('T- ~')

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19 cont'd

LICENSED SCALE MECHANICS

C:OMPANY

LOCATION

Licensed as of 1/13/95
CLASS

-AAA Scales & Systems Advanced Computer Sales Albany Scale Co. Albany Typewriter Exchange All American Business Machine A & MCD Scale and Equip American Eagle Equipment Co. American Standard Scales American Weighing Systems Atlanta Equip/Middle GA Scale Atlanta Scale, Inc. Bankhead Enterprises Bannex Corp. Berkel, Inc. Bi-Lo, Inc. Birmingham Toledo, Inc. Brewer Scale Ser Bulloch Scale Ser Capitol Business Equipment, Inc. Cardinal Scale Mfg. Co. Carolina Scale, Inc. Cash Register Exchange, Inc. Columbus Store Equipment Co. Conceptual Systems Corp. Cunningham Scale Co.
liey William J. Assoc. _~ata Cash Register Dataserv, Inc. Delta Scale Co. Delta Scale of Ga, Inc. Dickey Scales, Inc. Dickey Scales, Inc. Dixie Balance & Scale Co. Dixie Cash Register Co. Dutch Quality House East Tennessee Scale Works Fairbanks Scales Fairbanks Scales Fairbanks Scales Fairbanks Scales Federal Express Federal Express Federal Express Federal Express Fieldale Farms Fieldale Farms Corp. Gainesville Scales. Inc. Garys Mechanical & Elect Georgia Scale Co. GFI Service, Inc. Gold Kist Engineering -ceenville Scale Co.
Jbart Corp Hobart Corp

3232 Harmony Ch Rd Gainesville 3507 1702 N. Slappey Blvd Albany 3I70I PO Box 87I Albany 3I702 PO Box 724 Albany 3I703 739 McCalie Ave Chatt TN 37403 4248 Hwy 24 N hephzibah GA 308I5 PO Box 30056 Knoxville TN 37930 PO Box 216 Powder Springs 30073 PO Box 328 Oakwood 30566 1345 Capital Cir NW Lawrenceville GA 30243 9999 Tara Blvd Jonesboro 30237 I 080 Bankhead Hwy Atlanta 30318 5755 Hoover Blvd Tampa FL 33634 3095 Presidential Dr. SuiteD Atlanta 30340 Drawer 99 Mauldin SC 29662 #3 2nd Ave N Birmingham AL 35120 PO Box 714 Tucker GA 30085 Rt 3 Box 146 Stateboro GA 30458 675 S McDonough St Montgomery AL 36I04 I452 Kelton Dr. St. Mountain GA 30083 PO Box 8233 Columbus SC 29202 I 50 I St. Luke St. Augusta GA 30904 110I 6th Avenue Columbus GA 3I901 28 Rutledge St Nashville TN 37210-4287 1911 Hampton Ave Augusta GA 30904 PO Box 19060 I Atlanta GA 31119 10I8 Ist Ave Columbus GA 31902 5002 N Royal Dr Ste A Tucker GA 30084 5201 F Brookhollow Pkwy Norcross GA 30071 Rt 2 Box 13601 Milan GA 31060 7775 Remona Blvd Jax FL 32221 3009 N Slappy Blvd Albany GA 31701 1929 Moore Rd Augusta GA 30906 PO Box 736 Albany GA 31702 PO Box 2397 Gainesville GA 30503 IOOOO Martel Rd Lenoir City TN 37771 5970 E Unity Dr Norcross Ga 30071 AugustaGA ColumbusGA Albany 1797 NE Expy Atlanta GA 30329 2770 Gunter Park Dr Montgomery AL 36109 520 Airport Rd Chatt TN 37421 3401 Commonwealth Blvd Tallahassee FL 32303 PO Box 558 Baldwin GA 30511 Hwy 60 North Murrayville GA 30564 915 Ridge Rd Gainesville GA 30501 PO Box 144 Commerce GA 30529 3475 Old Petersburg Rd Augusta GA 30907 Rt 1 Box 614 Lenox GA 31637 PO Box 340 Valdosta GA 3I603 149 Landmark Dr Taylors SC 29687 3904 N Peachtree Rd Chamblee GA 30341 13 West Gate Blvd Savannah Ga 31405

1234 I 1234 I I 12 1 1234 1234 1234 I234 I234 I 1 I 1234 I2 12 I I234 1234 1 I 123 1234 12 1 1 12347 I2347 1234 12345 I2347 I 12 1234 1234 1234 I234 1234 12 I 12 1 12 1 1 12 12347 12 23 123467 1

TELEPHONE
706 532-2316 9I2 883-2398 912 436-2351 9I2 436-6541 6I5 624-7843 800 840-0836 615 588-8979 404 943-8455 404 532-1800 404 995-7554 404 477-7052 404 894-7923 813 884-2500 404 455-0795 803 234-183I 205 328-0904 404 934-536I 912 587-5464 205 265-8903 404 296-5400 800 277-2439 404 724-I747 404 323-5691 615 726-0001 404 738-5534 404 451-2411 404 324-2472 404 270-1730 404 263-9535 9I2 362-4676 800 275-0234 912 888-1600 404 793-1183 912 883-5900 800 241-3100 404 446-9000
404 728-5200 205 272-4127 615 855-6992 904 575-8600 404 778-5100 706 534-7373 404 53~7962 404 335-4591 706 855-1111 912 549-7191 912 244-7546 803 244-4723 404 458-2361 912 236-0004

CT- 83

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19 cont'd

Hobart Corp Hobart Corp Sales & Ser Hobart Corp Sales & Ser Hobart Corp Sales & Ser Hobart Corp Sales & Ser Hobart Corp Hormel Co Geo A Hot Lanta Scale o Howe Richardson, Inc. Industrial Scales & Systems Industrial Scales of GA Industrial Scales Service IBM Corp IBM Corp IBM Corp IBM Corp IBM Corp IBM Corp IBM Corp IBM Corp J H Harvey Co. KPS Sales Kroger Co Kroger Co Kroger Co Lab Tech, Inc. Mar-Jac Processing, Inc. McDonald Scale Co. Middle GA Scale Mid South Data Systems Mid South Data Systems Mid South Data Systems NCR Corp NCR Corp NCR Corp NCR Corp NCR Corp NCR Corp NCR Corp NCR Corp Palmetto Scale Service Peach State Scale Works Phillips Scale Service Postec, Inc. Raingo Scale Service Reliable Cash Register Rich Sea Pak Corp Rite Weight, Inc. S & S Scale Service Scale & Automation Systems Scale Data Systems, Inc. ScaleMan Scale Systems, Inc. Scale Systems, Inc. Scale Systems, Inc. Scale Systems, Inc. Shamrock Scale, Inc. Shamrock Scale, Inc. Sisson Scale & Equipment

PO Box 22403 Chatt TN 37404 622 Flint Ave Albany GA 3I70I 423 Crawford Avenue Augusta GA 30904 PO Box 4380 Columbus GA 3I904 PO Box 3282 JAX FL 32206 3I86 Mercer Univ Dr Macon GA 3I204 3367 Montreal Ind Way Tucker GA 30084 PO Box 43666 Atlanta GA 30336 4030 Poole Rd Winston GA 30I87 484 McBrien Rd Chatt TN 374I2 PO Box 46 Mableton GA 30059 300 E End Blvd S Marshall TX 75760 PO Box I9200 Jax FL 32203 Two Union Sq Tallan Bldg Chatt TN 37420 688 Walnut St Macon GA 3I20I 2743 Perimeter Pkwy Bldg IOO Augusta GA 309IO I276 Jessie Jewell Pkwy Gainesville GA 3050I 450 Mall Blvd Savannah, GA 30406 PO Box 7128 Columbus GA 3I90I 2425 Westgate Blvd Albany GA 3I707 PO Box 646 Nashville GA 3I639 I7I9 Brandy Woods Trail Conyers GA 30208 PO Box 105520 Atlanta GA 30348 Brunswick GA: Contact Atlanta Office Augusta GA: Contact Atlanta Office PO Box 3303 Marietta GA 30061 PO Box 1017 Gainesville GA 30503 4295 Cromwell Rd Ste 260 Chatt TN 37422-2284 290I JoycliffRd Macon GA 31211-2800 Duluth GA Contact: Asheville NC 780 Hendersonville Rd Asheville NC 28803 S Artillery Rd Taylors SC 29687 3731 Northcrest Rd Atlanta GA 30349 130 Conway Dr. Suite G Bogart GA 30622 1220 W Wheeler Pkwy Ste F Augusta GA 30909 106 Shoppers Way Brunswick GA 31520 1000 Business Ctr Dr Ste 30 Savannah GA 32256 506 45th St Bldg B Suite 8 Columbus GA 31904 I06 East 8th Street Rome Ga 736 Riverside Dr Macon GA 3I20I PO Box 324 Irmo SC 29063 PO Box 42407 Atlanta GA 303I1 5390 Frances Ave St Mountain GA 30087 2250 Northwest Pkwy Ste D Marietta GA 30067 PO Box 43I Rockford AL 35136 PO Box I83 Rome GA 30I6I 200 Glyndale Dr Brunswick GA 3I522 3802 Irvindale Rd Duluth GA 30136 Rt 2 Box 136 Byron GA 3I008 2299 Brockett Rd Tucker GA 30084 3772 Pleasantdale Rd Suite 190 Atlanta GA 30340 43I5 Highsmith Rd Gainesville GA 30507 6269 McDonough Dr Norcross GA 30093 472 Flowing Wells Rd Augusta GA30907 585 Lower Poplar St Macon GA 3I20I 1212 Metro Dr Columbus GA 31907 PO Box 931 Dalton GA 30722 9402 Hwy 92 Ste 102 Tampa FL 33610 123 Prosperity Dr. Savannah GA 31408

I I I I2 I2 I2 I23 I234 I234 I234 I234 I234 I
I I I I I I 7 1 1 1 7 12 1234 1234 1 I 1 1 1
I I I I234 I2 I2 1 234 I I I I234 12 1 1 1234567 I234 1234567 1234567 1234 1234 1234

6I5-899-3366 9I2-436-7I05 404-733-0950 404-327-7547 904-356-1376 912-746-5365 404-939-4880 404-346-0400 404-942-9944 615-499-22IO 404-94I-8879 903-935-3!)27 904-390-6700 6I5-755-3500 912-738-3163 404-868-3000 404-536-2071 9I2-351-2I05 404-57I-3000 9I2-434-4520 9I2-686-7654 404-922-9605 404-209-6630 912-267-0320 404-209-6630 404-422-3305 404-536-056I 615-899-580I 912-743-5544 704-274-425I 704-274-425I 803-244-705I 404-936-6502 404-548-9097 404-863-666I 912-265-6548 912-65I-7450 404-324-7347 404-29I-2648 912-743-3509 803-78I-2020 404-7 63-0092 404-38I-2203 404-422-7609 205-377-4924 706-295-5652 9I2-638-5000 404-476-8500 9I2-956-2410 404-939-7922 404-908-9616 404-535-2019 404-449-7770 404-855-5417
404-568-3508 706-226-0977 813-626-9225 912-966-2114

f""'T' QA

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-19 cont' d

South GA Scales Technology Service Solutions
JA Scale Supply Inc. fhomas Concrete ofGA Toledo Scale Co Toledo Scale Co Toledo Scale Division Turner Scale Ser Van Zant Enterprises Inc. Wayne Farm/Continental Grain Weighing & Control Service Weigh-Systems Whitaker Scale Service Wiggins Scale Co Wilde Scale Service Williams Bros/Blue Circle Wingfield Scale Co Zartic Inc Zartic Inc

PO Box 999 Ray City GA 31545 5555 Oakbrook Pkwy. Ste 180 Norcross GA 30093 PO B.ox 23001 Chatt TN 37422 1745 Phoenix Blvd Ste 480 Atlanta GA 30349 36581/2 Buena Vista Rd Columbus GA 31906 6148 Hawkinsville Rd Macon GA 31206 5680 Oakbrook Pkwy Ste 175 Norcross GA 30093 581 B George Todd Dr Montgomery AL 36117 6008 Minneola St Panama City FL 32404 PO Box 69 Pendergrass GA 30567 PO Box 2374 Brandon FL 33509-2374 154 Broad St Tallapoosa GA 30176 Rt 2 Box 753 Broxton GA 31519 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 808 West Ave Cedertown GA 30125 438 Lavendar Dr Rome GA 30161

12 I 1234 12 1234567 1234 12345 1234 7-Belt 12 7-Belt 1234 1234 1234 1234 7Hopper 1234 12 12

800-425-5678 404-447-5390 615-894-4657 404-447-4841 800-282-9721 912-781-6126 404-447-1401 205-271-3232 904-871-4544 404-693-2271 813-689-5785 404-574-8253 912-375-4804 404-872-4994 404-677-3286 404-499-2800 615-698-3346 404-748-2700 404-234-3000

CT-85

GA WIC PROCEDURES MANUAL FY '97 ACTION CODE DEFINITIONS:

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 r~paired 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.

Type of Scale: 01

Dial 02 03 04 05 06

Computing Balance Beam or Portable In Floor Electronic

Device Use:

A code can be generated by your department for this area; such as, 01 =County Health Center, 02 = WIC Center, 03 =Mental Health Center, 04 =High School Clinic, etc.

Source: Georgia Department of Agriculture, Fuel and Measures Division, 1995.

GA WIC PROCEDURES MANUAL FY '97

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,

"1 0% 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 ofthe 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- 87

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-20 cont'd

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

WEIGHT FOR HEIGHT TABLE

FOR DETERMINING WIC ELIGIBILITY

(SoCPct:: Aler,opOhtn Li'e IMv,nce Comp.ny. 1'93:3.1

~h(
-(57")

,.,..
~ 101

-.....wL
106-118

20'Io
~ 134

, ... (58"")

103

108 .. 120

137

4"11"(59"1

105

110-123

1oCO

s-o-(60")

107

112-126

143

5"1"(61"1

110

us- t2'9

146

5"2"(62")

112

1111-1.32

150

5"3"(63"1

115

1211:35

154

5"4-(6<"1

118

12.C -138

157

5"5"(65"1

121

5"6"'(66"1

12:!

127-1~1
130-144

,1.6.1.

s-r(Sr"}

1:2<;

133-1.(7

168

5"1"(68"1

129

'136- 150

172

5"9"(6.,

131

139-153

17:5

$"tcr(70I

134

142-156

17'9

NAME 1

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

1 :2 '2 4 6 8

_:) :3 36_"3 40
48 -46 -44

40 38 36 34

32

32

PIO~ .....etgrn g.ain on nocmal

c:unoe 4.WesS wom~n is 10"4 or 30

30

om-oerer~ ~tn . Ot t' c. arryi2..ft0O-..o.;rnsm. ore 28

28

26

26

24

24

22

22

Height in inches

(without shoes)

20

20

18

18

Weight History

16

16

(if not recorded in chart) 14

14

12

12

OATE

WEIGHT

~

10

10

8

8

6

6

4

4

2

2

0

-2

~

~

~

~

~~=

-a
-10

1.1 2

16

2

~4

Weel<s ol Pregnancy

~ ~
-a
IU
::36 ::3

r''T'- QQ

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-20 cont'd

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT

WEIGHT FOR HEIGHT TABLE

_. . , _ , """' FOR DETERMINING W!C EL!GfB!LfTY
(Source: U~ttopol!l~n t.~t.e ln$..,rance Comt)Jny. 1963.1
1....
~ Nomu:tWt.

~-.- (ST"J

101

106-118

"''

~1o-csa;

103

108-120

1:tl'

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT
NAME

C"11'"(59j

105

110 -12'3

1~

S"0"(60j

107

112-126

1C3

48

S"1"(61j

110

11S129

1~6

S"%"(6%")

112

118-13:2

150

46

5"3"(63"1

11S

121 -13S

1~

44

S"C"(G-<j

118

12.C -138

1$7

42

S"S"(6Sj

121

127-141

161

5"6"(66")

123

130 1.CC

16-<

40

S"T(67j

126

13:3-1.C7

16$

5"8"(64")

129

136 150

172

S"S"(6Sj

131

139-153

17S

5"10"(701

13<

1C2 156

17S

32 Plot -etgtu g.a.n on nOf'nqf

cunoe unles.s woman ~ tO% or 30

mote u~nt. 20"11. Ot mote

~(.OtColtf'Y'ftg hwins.

2S

26

24

22

Height in inches_ _ __

(without snoes)

20

18

8~~~++~~++4;-r~ 6~4-~4-~4-~~~~rr~~ 4 2 0
l------1r----; 2
-4 -6
.. -a
cf 10
WeeksoiP~

CT- 89

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-21

DIETARY ASSESSMENT

Each district must have an approved fobn 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 of Nutrition for approval. Any subsequent change(s) in the form and/or method must also be submitted to the Office of Nutrition: for approval.

Diet assessment forms and/or methods are evaluated by the Office ofNutrition using 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.

rT- Of'l

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

...

Select the appropriate charffor 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

_::8..

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.

rT- 01

GA WIC PROCEDURES MANUAL FY '97 To round off the child's age, follow these rules:

Attachment CT-22 cont'd

0-15 days 16-31 days 0- 1 month 2- 4 months 5- 7 months 8-10 months 11 - 12 months

-round off to the previous month -round off to the next highest month -round off to the previous whole year -round off to 114 year -round off to Yz year -round off to 3/4 year -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 of height/weight 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.

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GROWTH CHART FOR GIRLS: BIRTH TO 36 MONTHS OF AGE

N~E----------------------------DATE OF BIRTH _ _ _ _ _ _ _ _ __

GROWTH CHARTS WITH REFERENCE PERCENTILES FOR GIRLS BIRTH TO 36 MONTHS OF AGE
Length for Age Weight for Age Bead Circumference for Age Weight for Length
RECORD# ____________________________

DATE OF MEASUREMENT

AGE IN MONTHS

RECUMBENT LENGTH

WEIGHT

HEAD CIRCUMFERENCE

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 Disease Control. The charts are based on data from the Fels Research Institute, Yellow Springs, Ohio. These data reappropriate for young girls in the general U.S. population. Their use will direct attention to unusual body size which may be due to disease or poor nutrition.
Measuring: Take all measurements with the child nude or with minimal clothing and without shoes. Measure length with the child lying on her back fully extended. Two people are needed to measure recumbent length properly. Use a beam balance to measure weight.
Recording: First take all measurements and record them on this front page. Then graph each measurement on the appropriate chart. Find the child's age on the horizontal scale; then follow a vertical line from that point to the horizontal level of the child's measurement (length, weight or head circumference). Where the two lines intersect, make a cross mark with a pencil. In graphing weight for length, place the cross mark directly above the child's length at the horizontal level of her height. When the child is

measured again, join the new set of cross marks to the previous by straight lines.
Interpreting: 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 chart contains a series of curved lines numbered to show selected percentiles. These refer to the rank of a measure in a group of 100. Thus, when a cross mark is on the 95th percentile line of weight for age it means that only five children among I00 of the corresponding age and sex have weight greater than that recorded.
Inspecthe set ofcross marks you have just made. If any are particularly high or low (for example, above the 95th percentile or below the 5th percentile), you may want to refer the child to a physician. Compare the most recent set of cross marks with earlier sets for the same child. If she has changed rapidly in percentile levels, you may want to refer her to a physician. Rapid changes are less likely to be significant when they occur within the range from the 25th to the 75th percentile.

DEPARTMENT OF HEALTH, EDUCATION, AND \VELFARE, PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION, NATIONAL CENTER FOR HEALTH STATISTICS, AND CENTER FOR DISEASE CONTROL

CT-93

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GIRLS FROM BIRTH TO 36 MONTHS

GIRLS FROM BIRTH TO 36 MONTHS
WEIGHT FOR AGE
A~(~~~
18

.

7

y

' '

-t-i : -;-;-+-

36

kg..

-1-18

- 17 16

..n!!!. 15
,..
~

..:5&11. 13

lOttt 12
ICit

11

f-

10 j.

-

~

s
--
7
--
6
5

3

0

o

0

6

12

18

(.-ntt.sj

{'T _ OLl

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GIRLS FROM BIRTH TO 36 MONTHS

GIRLS FROM BIRTH TO 3& MONTHS

HEAD CIRCUMFERENCE FOR AGE

~~~)

12

18

36

k~.
18

21

23

25

so

29
70

15 14

1:3

12
11~
~
22 10

. ~
.:~

It..-...;......_- .

., ..
. ~t+; -.;..:.~~ -
. !+i-~ ..

20 9 18 16 14 12 10

31

33

.. H

8

6

4 37

100 em.

WEIGHT FOR LENGTH

CT- 95

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GIRLS FROM BIRTH TO 36 MONTHS

GIRLS FROM BIRTH TO 38 MONTHS
LENGTH FOR AGE

0

6

12

18

36

, . (months)

f'T-Qh

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GROWTH CHART FOR BOYS: BIRTH TO 36 MONTHS OF AGE

_____________________________
N~E

GROWTH CHARTS WITH REFERENCE PERCENTILES FOR BOYS BIRTH TO 36 MONTHS OF AGE
Leogth for Age Weight for Age Head Circumfereoce for Age Weight for Leogth
RECORD# __________________~--------

DATE OF B I R T H - - - - - - - - - -

DATE OF MEASUREMENT

AGE IN MONTHS

RECUMBENT LENGTH

WEIGHT

HEAD CIRCUMFERENCE

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 Disease Control. The charts are based on data from the Fels Research Institute, Yellow Springs, Ohio. These data reappropriate for young boys in the general U.S. population. Their use will direct attention to unusual body size which may be due to disease or poor nutrition.
Measuring: Take all measurements with the child nude or with minimal clothing and without shoes. Measure length with the child lying on his back fully extended. Two people are needed to measure recumbent length properly. Use a beam balance to measure weight
Recording: First take all measurements and record them on this front page. Then graph each measurement on the appropriate chart Find the child's age on the horizontal scale; then follow a vertical line from that point to the horizontal level of the child's measurement (length, weight or head circumference). Where the two lines intersect, make a cross mark with a pencil. In graphing weight for length, place the cross mark directly above the child's length at the horizontal level of his height When the child is

measured again, join the new set of cross marks to the previous by straight lines.
Interpreting: 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 chart contains a series of curved lines numbered to show selected percentiles. These refer to the rank of a measure in a group of 100. Thus, when a cross mark is on the 95th percentile line of weight for age it means that only five children among 100 of the corresponding age and sex have weight greater than that recorded.
/nspecthe set ofcross marks you have just made. If any are particularly high or low (for example, above the 95th percentile or below the 5th percentile). you may want to refer the child to a physician. Compare the most recent set of cross marks with earlier sets for the same child. If she has changed rapidly in percentile levels, you may want to refer him to a physician. Rapid changes are less likely to be significant when they occur within the range from the 25th to the 75th percentile.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION, NATIONAL CENTER FOR HEALTH STATISTICS, AND CENTER FOR DISEASE CONTROL

CT-97

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

BOYS FROM BIRTH TO 36 MONTHS

BOYS -FROM BIRTH TO 36 MONTHS

WEIGHT FOR AGE
Ag~ C...Ontktl

0

6

12

18

24

30

36

24 ~ 22
c"; '
3:
20 18 16 14 12 10 8 6 4
2 0
0

10 ~
~
9 8 7
(;
5
4
3 2

-.----.-- -

6

12

18

24

30

36

AQe (months)

rT_O~

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

BOYS FROM BIRTH TO 36 MONTHS

BOYS FROM BIRTH TO 36 MONTHS

HEAD CIRCUMFERENCE FOR AGE

in.

0

6

12

tB

24

30

36

:lG

36

f4

11 32

6
s

3

2

20

26

28

30

32

34

36

38

in.

70

100

WEIGHT FOR LENGTH

CT- 99

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

BOYS FROM BIRTH TO 36 MONTHS

in. 0 <Z
~
38 36 3<4 3:2
.&:
.c
c ...J 30
0

BOYS FROM BIRTH TO 36 MONTHS
LENGTH FOR AGE

1'2

24

30

9g
96 94 gz .
90 gg
86 84

60
...cc;.
c "76 ....l
74
7:
70
68
66
o4
64
60
ss
56.

S<l

5Z ")

4<

.'!;,

6

12

tS

24

:lO

36

Age (months)

f"'T 1 f\f\

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GROWTH CHART FOR GIRLS: 2 TO 18 YEARS OF AGE

N~E---------------------------DATE OF BIRTH-------------------

GROWTH CHARTS WITH REFERENCE PERCENTILES FOR GIRLS 2 TO 18 YEARS OF AGE
Stature for Age Weight for Age Weight for Stature
RECORD# _____________________________

Date of Measurement

Age Years Months

Stature

Weight

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 Disease Control. The charts are based on data from national probability samples representative of girls in the general U. S. population. Their use will direct attention to unusual body size which may be due to disease or poor nutrition.
Measuring: Take all measurements with the child in minimal indoor clothing and without shoes. Measure stature with the child standing. Use a beam balance to measure weight.
Recording: First take all measurements and record them on this front page. Then graph each measurement on the appropriate chart. Find the child's age on the horizontal scale; then follow a vertical line from that point to the horizontal level ofthe child's measurement (stature or weight). Where the two lines intersect, make a cross mark with a pencil. In graphing weight for stature at the horizontal level ofher weight When the child is measured again, join the new set of cross marks to the previous set by straight lines.
Do not use the weight for stature chart for girls who have begun to develop secondary sex characteristics.

Interpreting: 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 chart contains a series of curved lines numbered to show selected percentiles. These refer to the rank of a measure in a group of I00. Thus, when a cross mark is on the 95th percentile line of weight for age it means that only five children among 100 of the corresponding age and sex have weights greater than that recorded.
lnspecthe set ofcross marks you have just made. Ifany are particularly high or low (for example, above the 95th percentile or below the 5th percentile), you may want to refer the child to a physician. Compare the most recent set of cross marks with earlier sets for the same child. If she has changed rapidly in percentile levels, you may want to refer her to a 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, EDUCATION, AND WELFARE, PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION, NATIONAL CENTER FOR HEALTH STATISTICS, AND CENTER FOR DISEASE CONTROL

CT- 101

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GIRLS FROM 2 TO 18 YEARS

GIRLS FROM 2 TO 18 YEARS
WEIGHT FOR AGE

140

'30

2 3

5 6 7 8 8 10 11 12 13 1. 15 16 17 18 ,... (....-nl,

CT- 102

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GIRLS FROM 2 TO 18 YEARS

GIRLS FROM 2 TO 18 YEARS
STATURE FOR AGE

~~-~~

ln. z

19 - 6 - - . ; 7 - - 8

~

11 12

C"'

70

6S

66

110
. 2 3 4 6 a 7 I 0 10 11 12 l3 14 16 16 17 18
Aoe (yars)
CT- 103

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

PRE-PUBERTAL GIRLS FROM 2 TO 10 YEARS

PRE-PUBERTAL GIRLS FROM 2 TO 10 YEARS
WEIGHT FOR STATURE
~ I)()
85 80 75 70 65 E !?
i 60
--.
55

35 36 37 38 39 -40 41 42 43 . . 45 ~ 47 48 49 50 51 52 53 54 Suture (in.!
r'T _ 1 f\L1

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

GROWTH CHART FOR BOYS: 2 TO 18 YEARS OF AGE

NAJtlE ____________________________

GROWTH CHARTS WITH REFERENCE PERCENTILES FOR BOYS 2 TO 18 YEARS OF AGE
Stature for Age Weight for Age Weight for Stature
RECORD# _______________________________

DATE OF BIRTH----------

Date of Measurement

Age Years Months

Stature

Weight

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 Disease Control. The charts are based on data from national probability samples representative of boys in the general U. S. population. Their use will direct attention to unusual body size which may be due to disease or poor nutrition.
Measuring: Take all measurements with the child in minimal indoor clothing and without shoes. Measure stature with the child standing. Use a beam balance to measure weight
Recording: First take all measurements and record them on this front page. Then graph each measurement on the appropriate chart Find the child's age on the horizontal scale; then follow a vertical line from that point to the horizontal level ofthe child's measurement (stature or weight). Where the two lines intersect, make a cross mark with a pencil. In graphing weight for stature at the horizontal level of her weight When the child is measured again, join the new set of cross marks to the previous set by straight lines.
Do not use the weight for stature chart for boys who have begun to develop secondary sex characteristics.

Interpreting: 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 chart contains a series of curved lines numbered to show selected percentiles. These refer to the rank of a measure in a group of I00. Thus, when a cross mark is on the 95th percentile line of weight for age it means that only five children among I00 of the corresponding age and sex have weights greater than that recorded.
lnspecthe set ofcross marks you have just made. Ifany are particularly high or low (for example, above the 95th percentile or below the 5th percentile), you may want to refer the child to a physician. Compare the most recent set of cross marks with earlier sets for the same child. If he has changed rapidly in percentile levels, you may want to refer him to a 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, EDUCATION, AND WELFARE, PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION, NATIONAL CENTER FOR HEALTH STATISTICS, AND CENTER FOR DISEASE CONTROL

CT- 105

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

BOYS FROM 2 TO 18 YEARS

BOYS FROM 2 TO 18 YEARS
WEIGHT FOR AGE

lb. 220
210
200

190

180

170

160 150

140

E 130
~
i 120

110

100

90 80

70

60
so

40 30

20 2

34 5

6 7

8 9 tO 11 12 13 14 15 16 17 18
Age (yean)

rT _toll

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

BOYS FROM 2 TO 18 YEARS

PRE-PUBERTAL SOYS FROM 2 TO t1~ YEARS
WEIGHT FOR STATURE

80 75 ~
~ "
70 65 60 55 50 45 40 35 30

so 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49

51 52 53 54 55 56 57

Stature (in.l

CT -107

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-22 cont'd

PREPUBERTAL BOYS FROM 2 TO lllh YEARS

BOYS FROM 2 TO 18 YEARS
STATURE FOR AGE

in~

err.

76

74

72

70

68

66

64

62

60

58

.,

:;
;;;

56

.;;

54

52
so

48

46

44

42

40

38

36

34

.

: 32 -:-t__,...;-t--~~+--...;.....;....;..:..:;.-+.::~~~.::-+~-~--=..:..;_~----i

i
30

2 3 4 5 6 7 8 9 tO 11 12 13 14 15 16 17 18

AtJe (years)

Fonn2:Z.C5

l'.T- 1OR

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-23

WEIGHT FOR HEIGHT TABLE
FOR DETERMINING WIC ELIGffiiLITY*
~

Height

Underweight (10%+Below Normal Weight)

Normal Weight (Standard Weight)

Overweight (20/o+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% belowand 20% above. Allowance for three (3) pounds of clothing provided.

1. 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 ofNutrition, Division of Public Health, Georgia Department ofHuman
Resources, January, 1994. Based on the 1983 Metropolitan Life Tables.

CT- 109

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-24

Body Area Hair Eyes
Lips Gums Tongue
Face and Neck
Skin

PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Normal Appearance

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

shiny; firm; not easily plucked bright; clear; shiny; no sores at comers ofeyelids; 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

lack of natural shine; dull; dry; thin; loss of curl; color changes (flag sign); easily plucked

inadequate protein and calories

eye membranes pale;
Bitot's spots; red membranes; dryness of membranes dull appearance of cornea (cornmeal xerosis); softening of cornea (keratomalacia);
redness and fissuring of eyelid comers

anemia (inadequate iron, folacin, or Vitamin B-12)
inadequate Vitamin A
inadequate riboflavin, Vitamin B-6, and niacin

redness or swelling ofmouth or lips (cheilosis);
bilateral cracks, white or pink lesions at comers of mouth (angular stomatitis) and/or scars

inadequate niacin and riboflavin inadequate riboflavin, niacin, iron and Vitamin B-6

spongy; bleeding; receding

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 of skin around nostrils (nasolabial seborrhea)
swollen (moon) face; front ofneck swollen (thyroid enlargement) swollen cheeks (bilateral parotid enlargement)
dry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis);
pinhead-size purplish skin hemorrhages (petechiae); excessive bruising; red, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis); extensive lightness and darkness ofskin (flaky, pressure sores (decubiti)

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

Teeth Glands

no cavities, no pain, bright face not swollen

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

inadequate Vitamin D inadequate Vitamin A
inadequate iodine inadequate protein

I'T'- 11 ()

GA WIC PROCEDURES MANUAL FY '97

Attaclunent CT-24 cont'd

r \rea
Nails
Muscular and skeletal systems

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

Signs Suggestive of Nutrient Deficiencv(ies)

Nutrient Consideration(s)

nails are spoon-shaped (koilonychia); brittle, ridged nails, pale nail beds

inadequate iron Vitamin A toxicity

muscles have "wasted" appearance; baby's skull bones

inadequate protein

are thin and soft (craniotabes); round swelling of

inadequate thiamin

front and side ofhead (frontal and parietal bossing);

inadequate Vitamin D

swelling of ends of bones (epiphyseal enlargement);

small bumps on both sides of chest 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 (muscular-skeletal hemorrhages); person cannot

get up or walk properly

*As stated under nutritional risk criterion "I". Clinical Manifestations of Malnutrition, Dental Problems, Lead Poisoning."
Adapted from American Journal ofPublic Health. Supplement, November 1973, p. 19. and 1992 Georgia Dietetic Association Diet Manual.

CT -Ill

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-25

RECOMMENDED DAILY SERVINGS CHART

Food Group

Birth to 516 Months

Milk, Yogurt &Cheese

Breastmilk, every 2-3 hrs or Iron , fortified formula, 2.5 ozllb (18-35 ozs)

Meat, Poultry, Dry Beans, Eggs, Nuts Group

None

Fruit Group

None

Vegetable Group None

Bread, Cereal, Rice&Pasta Group

None

Other

None

~
516 Months to I Year
Breastmilk, every 2-4 hrs or Iron fortified formula, 2.5 oz!lb (24-35 ozs)
Add after 6 months and before 9 months

I-3 Year old' 2 servings (!6 ounces total)
3 ounces

4-6 Year old4 2 servings (16 ounces total)
5 ounces

Add after 6monthsand before 9 months
Add after 6 months and before 9 months
Add iron fortified cereal at 5-6 months
None

2 servings I serving= 3Tcooked/ pieces Y, fruit Y, cjuice

2 servings

3 servings I serving= 3Tcookedor chopped 2/3craw leafy

3 servings

6 servings I serving= Y, slice or 114 c cooked y, c dry
cereal

6 servings

As needed to meet RDA for energy

Pregnant Teen/ Pregnant Adult" 3-4 servings'
6 ounces 3 servings
4 servings
9 servings

BFTeen!BF Adult" 3-4 servings'
6 ounces 3 servings
4 servings
II servings

I Portion size is reduced by approximately I/3rd, except for milk 2 Pregnant and breastfeeding teenagers need 4 servings 3 Women 24 years and under need 3 servings 4 Recommended serving sizes:
Milk, Yogurt & Cheese Group: I Serving=
I cup milk/yogurt 11/2 ounces natural cheese(i.e. cheddar, colby, longhorn) 2 ounces processed cheese(i.e. american, swiss) 11/2 cup ice cream 2 cups cottage cheese
Meat. Poultrv Drv Beans Eggs Nuts Group: Other foods from this group count as I ounce of lean meat I serving=
I egg 1/3 cup nuts Y, cup cooked dry beans 2 tablespoons peanut butter

Fruit Group: I serving= I medium fruit 6 ounces juice Y, cup pieces
Vegetable Group: I serving= Y, cup cooked or chopped I cup raw leafy
Bread. Cereal. Rice & Pasta Group: I serving=
I slice Y, cup cooked cert:al, rice or pasta 1/4 cup dry cereal

TeenPP/Adult pp4 2-3 servings'
5 ounces 2 servings
3 servings
6 servings

rT _ 11'?

GA WIC PROCEDURES MANUAL FY '97

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. (1)

2.

Any practice of pica. (1)

Additional Inappropriate Food Practices for Prenatal Women:

1.

Intake of more than 300 mg of caffeine per day. (1, 4, 5, 6, 7)

2.

Intake of alcohol. (4, 9)

3.

Intake of less than 8 cups of clear liquids per 24 hours. (1)

Additional Inappropriate Food Practices for Infants:

Use of an infant feeder. (1, 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. (1)

5.

Introduction of solids prior to 5 months of age. (1, 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 breastmilk/infant

formula. (1)

Additional Inappropriate Food Practices for Children:

1.

Food consistently used as a pacifier or reward. (1)

Unflavored water not offered daily. (1)

CT -113

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-26 cont'd

~

3.

Drinking from the bottle after one (1) year of age, unless medically indicated. (7)

4.

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

References for Inappropriate Food Practices

(1)

Office ofNutrition, Division ofPublic Health, Georgia Department ofHuman Resources: Nutrition

Guidelines for Practice. 1986.

(2)

Committee on Nutrition: Pediatric Nutrition Handbook. American Academy of Pediatrics, 1993.

(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 ofReproduction

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, P.A.: Maternal Caffeine Use Before, During and After Pregnancy and Effects

Upon Offspring. Neuro-behavioral Toxicology and Teratology, 7:9-17, 1985.

(8)

Georgia Dietetic Association, Inc., Diet Manual, Fourth Edition, 1992.

(9)

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

CT -114

GA WIC PROCEDURES MANUAL FY '97

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 Education/GED 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 lild 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 ofAFDC grant.

Food Stamp Employment and Training (E & T)

Provides benefits to participants in approved PEACH/Food Stamp employment and/or training activity residing inanE & T county.

Foster Child Care

Benefit recipients are children in foster care.

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

CT- 115

GA WIC PROCEDURES MANUAL FY '97 GEORGIA WIC PROGRAM
REFERRAL FORM
Georgia WIC Program Referral Fonn

Attachment CT-28

Name: Address:

USDA policy does not permit discrimination because of race, color, national origin, sex, age or handicap. Any person who believes he or she has been discriminated against in any USDA related activity should write immediately to the Secretary of Agriculture, Washington, D.C. 20250.
Date ofBirth:

Date:
Height
Weight Any nutritionally related medical conditions? Ifyes, specify:

Date: Hematocrit: Hemoglobin:

Yes

Nc

Any clinical manifestations of malnutrition? If yes, specify:

Yes

No

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

Yes

No

Any evidence of lead poisoning? If yes, specify:

Yes

No

WOMEN ONLY EDC/DeliveryDate: - - - - - - - - - - - - -
Blood Pressure:

Number of Previous Pregnancies - - - - -

Live Births - - - - - - -

INFANTS ONLY Breastfeeding:

Yes

No

Birth weight:

Weeks Gestation:

HEALTH PROFESSIONAL

Signature/Title

Agency Address

Breastfeeding: Date Taken:

Yes

No

Miscarriages, Abortions - - - - - - -

Pregravid Weight - - - - -

Birth length:

Agency Telephone

CT- 116

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-29

NUTiuTIONAL RISK PRIORITY SYSTEM

1.

Priority 1: 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.

2.

Priority 2: 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.

3.

Priority 3: 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.

4.

Priority 4: Pregnant women, breastfeeding women and infants with a nutritional need because of

poor diet or homeless/migrancy status.

5.

Priority 5: Children with a nutritional need because of poor diet or homeless/migrancy status.

6.

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

status and homeless/migrant postpartum non-breastfeeding teenagers.

CT -117

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-30

GEORGIA WIC PROGRAM VOCCARDAGREEMENT

District

Unit

would like to have a clinic representative order VOC Cards directly

from the State WIC Office.

In order to accommodate this request, the attached form (Attachment II Cont'd) must be completed.

Signed:___ _ _ _ _ _ _ _ _ _ _ _ _ __ WIC Program Coordinator

Date_ _ _ _ _ _ _ __

IN SIGNING TIDS FORM, I REALIZE THAT IF THE CLINIC REPRESENTATIVE CHANGES, I MUST CONTACT THE STATE WIC OFFICE TO INFORM THEM OF THE CHANGE.

CT- 118

GA WIC PROCEDURES MANUAL FY '97 VOCCARDFORM

Attachment CT-31

District---J Unit_

VOC Card Form

Attachment II Cont'd

In an effort to begin sending VOC cards directly to the clinic from the State WIC Office, the following form must be on record at the State WIC Office.

1.

Please list the information requested below:

CLINIC NAME/#

# OF VOC CARDS ISSUED
(Three Month Period)

STAFF PERSON
Clinic Representative

...

'
2. How many cards do you currently have on hand at the District Office? _ _ __
NOTE: THIS SURVEY IS A ONE TIME SURVEY TO BEGIN THIS PROCESS
CT- 119

GA WIC PROCEDURES MANUAL FY '97
~
CENTRAL SUPPLY REOUISITION

Attachment CT-32

GEORGIA DEPARTMENT OF HUMAN RESOURCES

CENtRAL SUPPLY REQUISITION



Suite J

1150 Murphy Avenue, S.W.

Atlanta. Georgia 30310

INVOICE No.7 32229

INVOICE NO. 732229

SENDTO: ________________~--~~~--------------(Name of Office) (Name of Division)
(Street Address or State Office Room Number)

COUNTY: _ _ _ _ _ _-::-:-----:----

(Name}

(Number)

DATE:

W-W-W

w LuJ Lu.J Lu OCORDGEA:NIZATION

-

-

-

(City)

(State)

(Zip Code)

BO BACKORDER-DO NOT REORDER

EXPLANATION OF CODES

c QUANTITY CUT/PLEASE REORDER
N NOT STORED IN CENTRAL SUPPLY

0 CHECK ONE:

Office Supply 100000

0 Forms Supply

DIVISIONID NUMBER:

LuJ

I I R REFERRED

L REPRODUCE LOCALLy

~ FILLED

I ID DISCONTINUED

v VOID. PREVIOUSLY SHIPPED

Form No./ltem No.

Unit of
Issue

Quantity

Code

Desaiption

..

FOR CENTRAL SUPPLY USE ONLY
ORDERED BY:
TELEPHONE:

STOCK NO.
1000000450 . 1000000451 1000000452

UNIT OF ISSUE EA EA
EA

UNIT COST

(Name)

OTY.

ORGANIZATIONAL CODE

CODE DESCRIPTIOt

1

UPS(3-22-47E

1 L.__U -l..J...--LJ -l..J...--LJ -I I I I
1

Parcel Post Freight

FOR CENTRAL SUPPLY USE ONLY

(G1st. No.)

(Area Code)

(Phone No.}

Form 5014 (Rev. 10-88)

SEND ORIGINAL AND TWO COPIES TO CENTRAL SUPPLY TERMINAL COPY

CT- 120

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-33

STATE/DiSTRICT/CLINIC TRANSMITTAL FORM

Georgia Department of Human Resources
STATE/DISTRICT/CLINIC TRANSMITTAL FORM
The State/District/Clinic Transmittal Form is a three (3) part form used to transmit VOC Cards from the State WIG Office to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. The State WIG Office will forward orders of VOC cards within five (5) days of receipt.

State Use Only
District Name/#:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Clinic Name/ #: -----'-'~ Staff Name/Title Making Request: - - - - - - - - - - - - - - - - - - - - - - - - Date of Request: - - - - - - - - - - - # of Card(s) Sent: Signature of Requesting State Staff: - - - - - - - - - - - - - - - - - - - - - - - Serial # of Card(s) Mailed: - - - - - - - - to: - - - - - - - - - - - - - - - - - - -
Clinic Use Only
Date VOC Card(s) Received:---------
Date
# of Card(s) Received: Serial #of Card(s) R e c e i v e d : - - - - - - - - - - - - to: Signature of Staff Requesting/Receiving VOC Card(s):
Signature
Date Copy Sent to State/District Office: - - - - - - - - - - -
Date

Form 3699 (12-95)

White Copy - State WIG Office Canary - Clinic Pink - District
CT- 121

GA WIC PROCEDURES MANUAL FY '97

Attachment CT-34

GEORGIA WIC PROGRAM. WIC INCOME POVERTY GUIDELINES

WIC INCOME POVERTY GUIDELINES (185%) Effective March 23, 1996 through June 30, 1997

Family Size
1 2 3 4 5 6 7 8

Yearly
$14,319 $19,166 $24,013 $28,860 $33,707 $38,554 $43,401 $48,248

Monthly
$1,194 $1,598 $2,002 $2,405 $2,809 $3,213 $3,617 $4,021

Weekly
$276 $369 $462 $555 $649 $742 $835 $928

FOR EACH ADDITIONAL FAMILY MEMBER ADD

YEARLY

MONTHLY

WEEKLY

I

$4,847

I

$404

I

$94

I

CT- 122

TABLE OF CONTENTS

Page

I.

Rights and Obligations ofWIC Applicants/Participants ................ R0-1

II.

Nondiscrimination Clause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-2

III.

Public Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-3

IV.

Civil Rights

A. "...And Justice for All" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-3

B. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-3

C. Racial/Ethnic Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-3

D. Collection of Racial Ethnic Data ............................ R0-4

E. Discrimination Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-4

W~ ~~f.t~ijf9P~P!~!1!' . Ht.U'''P::f:}]~\:l:lTI~tisfi1f::]i:\PF~T:7' ... .;m:gr-;RQ~

J::}i

~~PWZ&eppl@P.~> .... .:;~;[.Jf;:m;t:::'o. ....

. c;r::'.R04

F~

fi!M~mltt%2~1i~S~<;Y:!~~:;.;g:::;ws1r:m:r&lt;:;:nu:: _;_TT:i .... . v?r;R<Yis

V.

Fair Hearing Procedures- Participants ............................. R0-6

A. Hearing Official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-7

"B. Request(s) for Hearing .................................... R0-7

C. Claimant's WIC Program Record Summary Form .............. R0-8

D. Case Record Disclosure Prior to Hearing . . . . . . . . . . . . . . . . . . . . . R0-9

E. Adjusting Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-9

F. Continuation of Benefits .................................. R0-9

G. Denial or Dismissal of a Request for a Hearing . . . . . . . . . . . . . . . . R0-10

H. Notification ofthe Hearing ............................... R0-16

I. Conduct ofthe Hearing and the Claimant's Rights ... , ......... RO-ll

J. Attendance at the Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RO-ll

K. The Hearing Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RO-ll

L. The Hearing Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-12

M. Notification of the Hearing Decision . . . . . . . . . . . . . . . . . . . . . . . . R0-12

N. Appeal Rights ofthe Claimant ............................. R0-13

0. State Rules ofProcedure ................................. R0-13

VI.

Fair Hearing Procedures - Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-13

VII.

Administrative Appeals - Local Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-13

Page

VIII.

Availability of Hearing Records

R0-14

IX.

National Voter Registration Act ................................. R0-14

Attacliments: R0-1 Rights and Obligations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R0-15 R0-2 Claimant's WIC Program Record Summary .............................. R0-17

GA WIC PROCEDURES MANUAL FY '97
I. RIGHTS AND OBLIGATIONS OF WIC APPLICANTS/PARTICIPANTS
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 information and follow program requirements.
The rights and obligations of a WIC applicant/participant in Georgia are printed on a If;!?~!.~~~ (Attachment R0-1) that must be given to every applicant/participant at
each certification. The applicant/participant must be asked to read (or have read to them)
or the RfgljTgt:l#;QPJigittiPI:iS; and be allowed to ask any questions. At each certification, the
partfcip.ant . .parent/caretaker/guardian must sign the back of the WIC Assessment/Certification Form to indicate that he/she has been advised of these rights and obligations. The applicant must read or have read to them the certification statement on the back of the certification form. After reading the Rights and Obligations, and Certification Form, the applicant/participant must sign. An explanation ofthe following items at initial certification may avoid future fair hearings:
1. Certification Reason 2. Benefit of Program 3. Rights and Obligations while on the program 4. Ineligibility Reason 5. Items that can/can not be purchased.
In addition to the rights and obligations stated on the I~?Q~~' 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.
Each participant on the WIC Program is entitled to be treated with courtesy while in the Health Department or Grocery Store. A WIC participant must never be singled out in a grocery store by the use of intercom systems or coding systems that would draw attention to the fact that they are WIC participants. The use of intercom systems or coding systems when used this way is discriminatory. This type of discrimination, when reported to the State WIC Office, will be handled by the Program Management and Review Unit and/or Vendor Management Unit.
The section, Special Populations (SP), outlines procedures for insuring program participation for non-English speaking populations, !!~f.HS,~~tT~]ffi[Vi:[gqffiN.~~,;~g
~%\f~x~~~n~~
Handicapped persons must be treated equally with all other eligible applicants/participants. WIC Program services must be accessible without hardship to disabled applicants and
R0-1

GA WIC PROCEDURES MANUAL FY '97
. . . . .. participants, ~c:IaptW:a:Qt'S,:Ciiiti!7ii9I~Jie]:ljsgtlmmatedcag~nsfl)~9iUSe:()'fl!te:stY:I"e'(i:e:
~~~~:ali!9!ij9~g~:'j~~J!Xi)~~~?~~~~ft~~~~P.~a.-:~*!~#.:4x~!~~~es)T' ''--'-~
II. NONDISCRIMINATION CLAUSE
All State agencies are required to implement a public notification program to inform 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 materials include brochures, posters, visuals, and any other literature produced by vendors, formula companies 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 ofthe public hearing.
5. Newsletters that convey WIC benefits and participation requirements.
The current nondiscrimination statement is:
"This is an Equal Opportunity Program. Ifyou 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".
R0-2

GA WIC PROCEDURES MANUAL FY '97
fri~~~l]~$;~~:;o!eft'P~Yi'<!~:t/RlJ!fit!2i,!.'P.i,~~e~"~itlit>t:ff.it~ti61@.gflieJ?ti?gr<:@~"ilf.~.not r~q@'~9i!~ ~g~taip.:~eg(:)ii~~~~@P.~tig~~~!~~*t;
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 ofWIC 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.
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.
Each applicant/participant must be identified by race or ethnic group, ~~E_(.)r Iii?~}~!~~}. 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.
R0-3

GA WIC PROCEDURES MANUAL FY '97
2" 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 of Racial/Ethnic Data
Collection and reporting ofracial and ethnic participation data is a requirement ofTitle 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 District/Unit and State. This report should be reviewed and maintained in District/Unit files. Data must be maintained under safeguard which will restrict access to authorized personnel and maintained for 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 of the Office of Equal Opportunity if he/she feels discrimination has occurred.
1. Written Complaints
Persons seeking to file discrimination complaints may file them either with the Secretary of Agriculture, 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 ofthe Department of Agriculture no later than ten (1 0) days from the initial receipt ofthe complaint. The State WIC Office will send a copy of the discrimination complaint to the USDA Regional Office.
The complaints should include the name ofthe agency and/or individual towards which the complaint is directed, and include a description ofthe 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 of the complaint for the complainant. Every effort
R0-4

GA WIC PROCEDURES MANUAL FY '97
shall be rna~ 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 WIC 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, color, national origin, sex, age, or handicap).
e. The names, titles, and addresses ofpersons 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. ~~PRPX\9!A~ ~~1:ifpi~t~~pf'l:>~i~a!::~2',19.;~!~~f?%Qli~~.ge.~~1t~.p;.#H1it\Q~HtiiQ~9rg!,* 30303S
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.Action Officer:.. .... . ' . ,,. ':; ..,, ; ...;.,....:~.~ .;.; ;.; :
R0-5

GA WIC PROCEDURES MANUAL FY '97
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~~~~~~~; ![g;!.fl:W:~~~Ef!J!~@f.:g;~u~~~~-<J.tf'!!:~~;~g;~~,g~Y:~:!?~~~~1J.!~~~;m~ ~ffi!~ ~~?~f
!~1BUl~~~9;'f1RiPN!~~!~!1l%~wn!!!tl!:~~I~4~~~t11.!ItA.Y..!.l:.>~:m~P...P...P..gEP:. !.&!!~'t.lj$.J.~1i..E~1~~:~~f
V. FAIR HEARING PROCEDURES- PARTICIPANTS WIC Federal regulations require the State agency to establish a hearing procedure under which a person or his/her 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 his/her right to a fair hearing and ofthe 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.
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GA WIC PROCEDURES MANUAL FY '97
Focusing efforts at the time ofapplication should prove to be valuable in ensuring a more informed public, thus reducing the number of Fair Hearings. Also, at the time of fair hearing request, the WIC 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, including their rights and responsibilities concerning the hearing process, the role of the Adrrl'ini~tr(ltive L'ii\y 1t1~ge, the time frame for final decisions and any other pertinent uuormation: casescan th.en 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 @iil;decision has been rendered.
The following is the Georgia WIC Fair Hearing Procedure:
A. Hearing Official
The gm~e()f~~t~~q,t,\gpi!ll~tiY,~:g~g~js responsible for action on each fair hearing request. The ()fficebf~ta:te~@4~d!iril'lisffiitive li~gs, an impartial party,
is vested with full authority ill. the conduct of'the hearmg process. This includes the
conduct of hearings, keeping all files and records, and furnishing information for
proper reports. The ().:..f..f..l...'.:..o..r..;...~..~...e...a...f..i..(..t..:..~..C..i..lWn...'.ls.t..t a..t..i..\..f..e....H....e..[..Q...D.....'~-.?.. is fully responsible
for conducting hearings properly and promptly in accordance with the rules and regulations established by the State. The Q.......f.fic.e...;.;.'(..}.f.S..t..a....t..e....'.a....n....d....r...A.....:..f.f..i..i.l..i.i..i.'.i..s...t..r...a....u....y.......'.H.....e....a....t.i.l..i.g....s... shall have the authority to do the following:
1. Administer oaths or affirmations;
2. Request, receive, and make a part of the hearing record all evidence determined necessary to decide the issues being raised;
3. Regulate the conduct in the course of the hearing consistent with due process to insure an orderly hearing;
4. Render a hearing decision based exclusively on the hearing record and matters officially noticed.
B. Request(s) for Hearing
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GA WIC PROCEDURES MANUAL FY '97

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

mails or gives the applicant or participant the notice of adverse action to deny,

suspend, or terminate benefits. Fair hearing requests shall be submitted to the~~

M!~~lJ~~I?.fPp!:I@~QJ; 47 Trinity Avenue, Room ~!Tif!~, 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 R0-2). Within three (3) working days the completed form and written request shall be submitted to the ~~JZ,~g~t;i[~~~:Qfff.~, 47 Trinity Avenue, Room ~JJ.lf.B, Atlanta, GA 30334. A:tdp~t6rlli~:fdthF;h.mF5~~:~ent to the State WIC Office.: :if:th~ hearing request is filed initially with the ~~\%1gai::S..eryiC.~q:mc;:, a copy will be immediately forwarded to the local agenty~:ww. < :-:,... ..... , ,

The local agency has the responsibility of maintaining contact with the claimant and must report promptly to the ~&?1:~.~9..~11Q~e any change in circumstances, including changes in mailing:::~adfg~;~:~::~:As::86fi 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 ofthe local agency and the circumstances of the 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 J?~g!:l~ero.~esiQI.i.i~. The local agency will secure any additional evidence nec~ssary:f():F:ih~llerufug~

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GA WIC PROCEDURES MANUAL FY '97
D. Case Record Disclosure Prior to the Hearing
All docwnents and records to be used in the hearing will be available for examination by the claimant and/or his/her designated representative prior to 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 representative will be given an opportunity to copy any materials in the file which are relevant to the appeal. Confidential material which cannot be released to the claimant or his/her 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. Ifthe 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 ofthe claimant's decision on withdrawal. In the case ofwithdrawal, amendment, or reversal, the local agency shall notify the P.~S.~f~~YY.!s~,~ QJ:I;T~ immediately, attaching a copy of the withdrawal or new notification and a
stlrt1Ih3ry supporting the corrective action taken by the local agency. If time does not
permit written notification, the &''gl:lJ,~I:Y~S~~,Q:ffl9~ shall be notified verbally with immediate follow-up in writing.
F. Continuation Of Benefits
Participants who appeal the termination ofbenefits within fifteen (15) days from date of notification shall continue to receive Program benefits until the ~:!~~tf~Ii:~
aeCisioiE
-:;-:-:-.- ..,:.:~:~,-;.:.:-.:-':-.-:;
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
R0-9

GA WIC PROCEDURES MANUAL FY '97 status changed, pending the hearing decision.
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.
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 (1 0) days prior to the hearing, the Qf!!~i,R1;.!~!~1.!.~1\i.i~~~F~~y
preparation J!@.gg.,f:shall provide written notice to all parties involved to pennit adequate of the case. The notice shall contain the following: 1. A statement of the time, place, and nature of the hearing.
2. A statement of the 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. If the 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 if the 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.
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GA WIC PROCEDURES MANUAL FY '97
The A~~...s..t..f...~..~. Y..~".p a\.W;.Jfi..(lgt..: may change the time and place of the hearing upon his own motion or that by the J?aiti~~- The Adffiii]j_stmtive:r.:;a.w:Judg may adjourn, postpone, or reopen the hearing upon receipto:f'additionai ififorffiation at any time prior to mailing the hearing decision.
Should the exercise the option ofrescheduling the ~gmitji~gy;Illiil.W[ifdge:lli~Y .O......v............w.............,,,,,.......O.o.'.O.........
hearing, the claimant shall be given at least ten (1 0) days advance notice of such action.
I. Conduct ofthe 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 .4(fifiipjst:fativTJJ~v{Jtid~ shall exercise discretion and may conduct the hearing on th.e llewiy.emerged issue. In such instances, the hearing may be continued so all concerned may prepare additional evidence.
The claimant/designated 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
!\,~$@ti~'~[JJ~'o/iil4(ige shall be attended by a representative of the agency which
initiated the action bei:r1g contested and may be attended by the individual and/or his
representative. Other local agency staff may attend and participate in the hearing p .... recess at the discretion of the ~i:liT[tiJ~at~y&Ea'i?~!iid~:.e. .w..................... .Ov--.-.. ................. The hearing may also be attended by friends and relatives of the claimant if the claimant so chooses.
K. The Hearing Record
The ~dfiiiffis"fi'4:tiv~:r._ifw~Jifag~ shall compile lli,e official hearing ~cora:: (j?e:;Uij(l Iftiteix.l\~)Y.~92r~,}YJ#4:.e~Y~i&@r:v?m.~~ -9f::!i~llio/<!~a1j~~~~~ ~~4~~~1.1:~~# telatedtO::the actioif:beiri i'.._._.;.:o-o::-:-o":::._..,..,..:.o::-::"''''''~:-.:-oa: .:..p.p..-e:,.a,.,.l;.:e-/d'"~The record shall include:
RO -11

GA WIC PROCEDURES MANUAL FY '97

I. All pleading.s, 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 staff memoranda and dates submitted to the Hearing Officer in connection with the case.

L. The Hearing Decision

Decisions of the .A,.,.,d.,.,m,,,.,i...,.n...i...S;.,.,m.,.,.m,.,.,v.,.,e.,.,.:,.,.,:......a.....J.....a..,.,w,,,,W.,,,.:,,,.1,.,,J,,,,,u,,,,i,,,,:,,,,l,,,,,~,,,,e,,.,,L:.,,,,,i,,,, shall comp1y with Federal law' regulations, and policy and shall be based on the hearing record. The ;~::<:f;~~"'Y
a\f'~pgg~j: decision shall take into consideration only those issues C:iirectly. reiated
to the action being appealed and shall be based exclusively on evidence and other material introduced at the hearing. A decision by the ~~fi\f~1P~\@:[gge shall .
be binding on the local agency and shall summarize ilie.fcts.ofih~tciSe;speci:fy the
reasons for the decision, and identify the supporting evidence and the pertinent
regulations or policy. The decision shall become a part of the 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 ~flw!~~~l.!~)A~(Itif!ge

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
I"eversaFoftheaea5i<;l1: ~d!i:ffiliS.~~1y~;~t\Wi)JJ!Oge and shall advise that an appeal request may result in a

R0-12

GA WIC PROCEDURES MANUAL FY '97
N. Appeal Rights of.the Claimant
When a decision is adverse to the claimant, he/she has the right to appeal to a DHR Appe~l}ev1~\V~~ The claimant shall be allowed tll:iW{30) days to request review of the decision by the DHRA.~,pearReVie~et. TheDII.RAPP~aJ.R~yi~:W,'1.: shall have all the powers and delegated authoritY ofthe.Commissioner to make a decision. He/she
from may take additional testimony or remand the case to the AC!l~$tra~~}[{3aw'lui:Ige for
such purpose. The decision will be based upon the record the orlgma.lheanng as augmented before the App~g~!~\V~r and shall either affirm, reverse, or modify the original decision to assure full compliance with Federal law, regulations, and policy.
If the claimant requests review ofthe .A~ti\i{!:}:aw!~ager~ decision, the usual standard of promptness is automatically waived. The claimant and his legal representative shall be notified, in writing, ofthe decision ofthe ~p_pe~~g.e:V:i~~i and of his/her right to judicial review. If the claimant is dissatisfied with the decision of the !}~~,~~Y:~~~~' he/she has the right to pursue judicial review (e.g., civil court).
0. 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. 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 1:1~~~~~~~ID.~~~Qffic~and State WIC Office.
VII. ADMINISTRATIVE APPEALS- LOCAL AGENCY
W"ppJ1ciif:itlp~~p~t'~may appeal a State agency decision when application to participate
ili the WI.c"I>rogram 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.
R0-13

GA WIC PROCEDURES MANUAL FY '97
The proposed adverse-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.
In the event of a hearing, an administrative hearing panel will be appointed by the Director of the Maternal & Child Health Branch to hear local agency appeals. This panel will consist of one (1) local agency WIC Program Coordinator and two (2) representatives from the Division of Public 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 ofthe 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.
VIII. 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.
IX. NATIONAL VOTER REGISTRATION ACT
The National Voter Registration Act of 1993 (NVRA) mandates the WIC Program's obligation to offer voter registration opportunities to anyone entering a clinic for the application or recertification of WIC benefits.
Individuals wishing to register will be given a voter registration application and any assistance needed to complete the form.
In the event an applicant/participant is already registered or does not wish to register, a declaration statement will be appropriately coded reflecting their wishes.
These declaration forms will be kept on file at the local agency for a period ofp months.
R0-14

GA WIC PROCEDURES MANUAL FY '97

Attachment R0-1

Geo.rgia 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'' ~e.~l!~m~:'<fi~!~se~~~~ffl~I~P!.!2~~~:.!9J:&l~!<?~l@l~~~~!~n~?f::)Y~f:(~
~~geliq;~,~:qtm~'t?Pti>9~e.of.1~t~~~~!!~!J:5mrx~~4:.%~l?~?~!i#~.:emr~~!1/!9,1Y!Q. fi~.tW~~!~
~d p~i.P~!~i

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. * l'"f?Hi:.e~s~~e:2'1.ij'M&If<f2g~I~m:fltf~~P~9P,~~-I<?,~~>~!J.~mr~l:f!9!E!i~%"..!t.H1~
xs!1sa~f;
* 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. If you do not keep your appointments, the number of vouchers issued to you or your child will be reduced.

RO -15

GA WIC PROCEDURES MANUAL FY '97

Attachment R0-1 cont'd

SCHEDULE FOR PICKING UP VOUCHERS LATE

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

LATE PICK-UP

I I Number of Days Late

Women & Children

Less than 7 days late

full package

I

7-13 days late

I

14-20 days late

I

21-31 days late

3 vouchers issued (3/4 package)
2 vouchers issued (12 package)
1 voucher issued (1/4 oacka!Ze)

Infants

I

full package

I

full package

I

1 voucher issued (Yz) package

1 voucher issued (12 oacka!Ze)

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

LATE PICK-UP SCHEDULE ADDENDUM/ALTERNATE FOOD PACKAGES

Number of Days Late II Women & Children II

Infants

I

Less than 7 days late

II

full package

II

full package

I

7- 13 days late

6 vouchers issued

I

(3/4 package)

full package

14-20 days late

4 vouchers issued

I

(12 package)

1 voucher issued (12 package)

21-31 days late

I

2 vouchers issued (1/4 package)

1 voucher issued (12 package)

This is an Equal Opportunity Program. Ifyou 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.

Fonn 3768 (Rev.)

RO -16

GA WIC PROCEDURES MANUAL FY '97

Attachment R0-2

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

SECTION I- IDENTIFICATION

District/Unit._ _ _ __

_ ~CID# _____________

Applicant/Participant:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Claimant (if different from above):_ _ _ _ _ _ _ _ _ _ _ __

Address:

Street Number and Name

City

State

Phone Number:._ _ _ _ __

Representative:_ _ _ _ _ _ _ _ _ __

Zip Code

Applicant/Participant Race/Sex: (Circle item#)

1. white male 2. white female 3. nonwhite male 4. nonwhite female County:._ _ _ _ _ __ Date of Request:._ _ _ _ _ _ __

Date of Appointment:_ __

Date of Notification:._ _ _ _ _ __

FOR STATE OFFICE USE ONLY: Request number:._ _ _ __ Date request filed:....,...._ _ _ _ __
lf:li!(~;1!~i!&i:~~~~~w::R~if'!2\R~!~rcr:~f.iiit!!i:~~r'!~~1ff~9.!1~~,:c:r~J.~;:!I!:f.~!~ ~!1~~~;~g~!SY:.f!t.~!!:~-~~t~ii~'!~t;l.l_~~g;@t;~:~i6,~J@):~~:~~i!~:1~\V~':~~~~ ~~t.!!::~$.'!!~Y.#!~f!!~:~at_e.:tt:t~:feq~~f~!'':!t.~~g:~.lf:~Ct!i!~t!~'$.!~~.~~!~~~t~ii~~i\IJ!g;

R0-17

GA WIC PROCEDURES MANUAL FY '97

Attachment R0-2 cont'd

SECTION II- TYPE OF AGENCY ACTION OR INACTION

A. A~ency 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)
10. Other B. Agency Inaction (Circle item number):

Date Date Date
Date Date Date Date
Date
Date Date

1. Failure oflocal agency to meet processing standards: (specify)

2. Other: (specify)

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GA WIC PROCEDURES MANUAL FY '97

Attachment R0-2 cont'd

SECTION III- NARRATIVE SUMMARY OF AGENCY'S ACTION OR INACTION AND PRINCIPAL ISSUES INVOLVED IN THE REQUEST FOR HEARING
A. Basis for local agency's action or inaction (specify briefly):

B. WIC regulations applied by local agency:

C. Participant's income eligibility information:

Signature/Title ofWIC Personnel Signature ofWIC Coordinator

Prepare in triplicate
Original -:'D.H.....R.,..'.t..:e_ ga_ r.s.,e .r._o.,c...e...s...'.O.....f.f..,i..c.,. e
File Copy- State WIC Office
File Copy - District/Local Agency

Program Name

Address

City

State

Zip Code

Telephone Number

R0-19

TABLE OF CONTENTS

SECTION ONE- FINANCIAL MANAGEMENT

I. Agreement with State Agency ..........................................AD-1

II. Financial Procedures ..................................................AD-1

A.

B~ ?.ffi.PH!~~~:&9B~'@'ig[!~P!:I:''T':O: ~.=.~""''''CC<'!:7:'::.,:,:::=~~~?:?'0:.., /Cf?H~el

C. Monthly Income and Expenditure Report ..............................AD-3

III. Administrative Cost Categories .........................................AD-4

A. General Administration ............................................AD-4

B. Nutrition Education Costs ..........................................AD-5

C. Breastfeeding Costs ...............................................AD-7

D. Client Services ...................................................AD-8

E. Indirect Costs ....................................................AD-9

IV. Shared Costs ........................................................AD-9

A. Shared Operational Costs ...........................................AD-9

B. Shared Equipment ...............................................AD-10

C. Shared Personnel Costs ...........................................AD.-1 0

V:

''7!..AD~14 <

A. Introduction ....................................................AD-12

B. Time Study Participants ...........................................AD-13

C. Prior Approval ........................................... : ......AD-13

D. Summary Sheet(s) .............. : . ...............................AD.-15

E. Analysis .......................................................AD-15

F. Time Study Results ..............................................AD-15

G. Record Retention ................................................AD-16 VI. Definitions ofWIC Time Study Activities ................................A'D-16

A. Administrative ..................................................AD-16

B. Client Services ..................................................AD.-17

a:
D. Breastfeeding ...................................................AD-19 , E. Either Administrative or Nutritional Education .........................AD-20
F. Other ..........................................................AD-20 VII. Purchasing Procedures ...............................................AD-20
A. Equipment (Excluding Medical Equipment) ...........................AD-20 B. Medical Equipment ..............................................AD.-21 C. ADP Equipment Purchases $5,000-$25,000 ...........................AD-23 D. ADP Equipment Purchases $25,000-$200,000 .........................AD-24 E. Supplies .......................................................AD-25 F. Central Supply Forms ............................................AD-25 G. Prior Approval/Duplication ofWIC Forms ............................AD-26 H. Rental of Space .................................................AD-26 I. Rearrangement and Alternation of Facilities ...........................AD-27
~f&WJE
~rre~rrrr
A. Food Funds .....................................................AD.-29 B. Administrative Funds .............................................AD-29 IX Food Cost Projection Report ...........................................AD-29 X. Program Income ....................................................AD-29
SECTION TWO- PROGRAM ADMINISTRATION
~~ ~~!!1M~!w~x,2:r9.RrKiri::;:::r:::t:nmrg:;:m:I:::ii.:E&rEJEI&1ifilillllt:I::::;:;::;::.::::.::m:mi::':ri:mm:r;.:::..:.i::::it:,... ;..~:~;~Ir
A. Definition of Records .............................................AD-30 B. Records and Reports- Accessibility of Records ........................AD-30 C. Retention Schedule ..............................................AD-30 II. WIC Acronym and Logo ..............................................AD-34 A. Authority ......................................................AD-34

Page B. Official Use ....................................................AD-34 C. Special Use .....................................................AD-34 D. Unauthorized Use ................................................AD-35 III. Lobbying Restrictions ................................................AD-35

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AD-1 Sample Formulas ....................................................AD-43

AD-2 Index of Functional Activity Codes .....................................AD-45

AD-3 WIC Time Study Data Collection Form ..................................AD-47

AD-4 WIC/Family Planning Time Study Data Collection Form ....................AD-48

AD-5 Time Study Summary ................................................AD-49

AD-6 Information Needed for USDA Approval ofNon-Major ADP Equipment .........................................AD-50

AD-7 Memorandum of Understanding ........................................AD-51

AD-8 Contract Budget ....................................................AD.-55

AD-9 Monthly Expenditure Report ...........................................AD-56

AD-10 WIC Forms Available in Central Supply .................................AD.-57

AD-11 Nutrition Materials Available in Central Supply ...........................AD-59

AD-12 Equipment Inventory Form ............................................AD.-60

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'

GA WIC PROCEDURES MANUAL FY '97

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 ofthe 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 of the 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 III, E., Attachment 1.

Current instructions may be obtained from the District Administrator or the Public Health Grant-in-Aid Office.

Local Agency fmancial staff must have accessibility to all state and federal manuals which relate to the operation and management of WIC funds:

Georgia WIC Procedures Manual USDA FNS Instruction 808-1 OMB Circular A-87 and A-102 Grant-in-Aid Policy & Procedure Manual, Parts III.E, Attachment 1 and IX.A,B. 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

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GA WIC PROCEDURES MANUAL FY '97
maintained in the fmancial office and secured.
Hard copies of all computerized fmancial 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:
1. 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.
3. 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.
4. The current Merit System Pay Scale is to be used.for computing salaries.
5. For part-time employees, indicate percentage of WIC time used in computing salaries.
6. Each position m~t;~J2.1isted numerically, in Merit System position number order, using all seven digits assigned. This must be done, without exception$%fQJf~:g)ji~e with the Personnel Expense
Reimbursement Sy~teni'(PERS}"'"data.
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GA WIC PROCEDURES MANUAL FY '97
7. p~sig~iJ.!~P all anticipated position (or incumbent) changes using separate lines and amounts with explanations. When adding or reallocating positions effective early in the budget year, the yellow copy of Requests for Personnel Action ~1:191:1!4 ~@ 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.
8. Pensions and benefits are computed on regular salaries asi;t#~~"AAH E~4~~~I~~W~HQ~'!gq@:~:
If the county is projecting cost for Unemployment Insurance (Contributory), this expense should also be budgeted in this section.
9.
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 form, 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. Ifthe 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 '97

lll.

ADMINISTRATIVE COST CATEGORIES

A. General Administration

In general, allowable administrative and operational costs are those costs necessary to fulfill program objectives and are 100 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 salaries/benefits 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 ADP areas and audit tracking.

6. Fair hearing costs.

7. Liability Insurance*.

8. The cost of hatching and mailing Motor - Voter Registration applications as well as costs associated with maintaining a file of Motor-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 personal liability for

damages arising out of the performance of their duties.

No authority exists for the purchase or provision of liability

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GA WIC PROCEDURES MANUAL FY '97
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.
The following costs are allowable only with prior approval from the State WIC Office and U.S.D.A.:
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 (1/6) of its administrative funds on nutrition education. As long as there is sufficient and appropriate documentation, the following are allowable nutrition education costs:
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GA WIC PROCEDURES MANUAL FY '97
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 of persons 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.
6. Nutrition education materials, including the cost to develop, print, and distribute these materials. A contract for the development and production of materials is allowable, as long as the provisions of OMB 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
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GA WIC PROCEDURES MANUAL FY '97
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:
I. Salaries of employees who plan and/or perform breastfeeding promotion and support activities.
2. Breastfeeding
A. Breastfeeding aids such as breast pumps, breast shells, nursing supplementers, nursing bras and nursing pads, which directly support the initiation and continuation of breastfeeding.
B. Other costs associated with the purchase and availability of breastfeeding aids through the WIC Program such as insurance and service fees in providing breast pumps.
C. Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. Such items may include models to illustrate the use of various breastfeeding aids, dolls used to illustrate nursing, etc.
3. Individual or group sessions with participants, for the promotion and support ofbreastfeeding. 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 of breastfeeding promotion and support
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GA WIC PROCEDURES MANUAL FY '97
activities, including participant surveys.
6. Development/procurement and distribution ofmaterials, 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 of reimbursable agreements with other organizations, public or private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.
1f. 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 staff salaries/benefits, medical supplies and equipment necessary to conduct diet and health assessments required in the certification process.
2. Salary/benefits ofWIC staff who 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 of health 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 of rural participants to clinics, when prior approval
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GA WIC PROCEDURES MANUAL FY '97

has been given by the State agency. 8. Translation of materials and use of interpreters. 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 of Human 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 f. Central Supply g. Legal Services h. Procurement and Contracting I. 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.

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GA WIC PROCEDURES MANUAL FY '97

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.

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 ofthe 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 of benefits 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 time. 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.

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GA WIC PROCEDURES MANUAL FY '97
USDA and the State agency will pursue a recovery of Program 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.
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 ofaverage 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)
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GA WIC PROCEDURES MANUAL FY '97
V. TIME STUDIES
Documentation of Costs
The Georgia WIC Program will u!!],g~(Ai~I91l9Wi,ilg time study methodology until the Division of Public Health allocatfb!fmethodoiogy has been approved/when the DHHS Cost Allocation Unit has prescribed an alternative methodology(g1}!~!:1!:~ k\1~?!~M~~~~!~~:mp~J!f!~~i~!~i
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 Definitions Section VI). All time study methodologies (data collection f:Bf.m~, 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 of the 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 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 ofrequired 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.
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GA WIC PROCEDURES MANUAL FY '97
Federal regulations require the State agency to expend at least one-sixth of its administrative grant for nutrition education and the Food and Consumer Service (FCS) designated amount for breastfeeding activities. The State, in turn, requires local agencies to spend at least one-sixth of its administrative grant for nutrition education and designated amount for breastfeeding. The State agency must document the total amount of administrative 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 stafftime spent performing \VIC duties. 2Ji<f8~P.I~?~ time study data, along with
salary information, will be used by local agencies to compute WIC costs f6fc
~!fe\"f@.?~J:;tJ~ fi~ .#:~ 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-\VIC paid personnel if local agencies are using the time study to justify reimbursement of personnel costs.
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 0n 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. Analysis/Use. Each local agency must submit a plan ofhow the time study will be analyzed and used. This plan includes
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GA WIC PROCEDURES MANUAL FY '97
formulas, what the data and the formulas will be used for, and the summary sheets to be used (See Attachment AD-I for examples of formulas).
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 fzfteen (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 (1) activity code. Arrows cannot be used to document continuous activity. Since the activity performed 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. ~~
.=iliitlli~f~~t.~"~:~ta~~i:i#iiil4
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, ifan employee works nine (9) hours in
a day, the first eight (8) hours are recorded on that day. The activities performed in the ninth hour will be recorded on the day the compensatory time is taken.
4. Definitions. Definitions must be submitted for the activities
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GA WIC PROCEDURES MANUAL FY '97
or activity codes listed on your data collection form.
5. Minimum Time Sample: Time studies must be conducted for a minimum of four (4) consecutive weeks (>:foti~}~lP#~ g~~~f/{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 ~@r~e?(?.ll7Y~'Ptl.l$i tli~;~iil!.H1 fi~~:;y~~
Attachment AD-5 is an example of a sUl1111lary 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 compiling the analysis must be submitted to the State WIC Office. The formulas used for these calculations must have pt;ip~j)ipp.i:(}'(f~ (refer to III.). Local Agencies will receive
written approva:f ()f these calculations within thirty (30) days of
submission to the State WIC Office.
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 th~:fq!l~@ 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 of the 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 fmal calculations while conducting the on-site review. At the
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GA WIC PROCEDURES MANUAL FY '97
time of tli~ program review, if a time study has not been conducted and completed as 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 of the 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 defmed as Administrative, Client Services, Nutrition Education and Breastfeeding. They may include, but are not limited to, the 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.
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 fmancial 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 of fraud).
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GA WIC PROCEDURES MANUAL FY '97
5. All duties performed 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 Motor-Voter Registration Applications as well as maintaining a file of Motor-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/mid-certification assessment, e.g. filling out the turnaround document and WIC Assessment/Certification Forms, completing the Notice of Termination/Ineligibility/Waiting List Form.
4. Termination of a participant from the Program at any time other than during a certification/subsequent certification appointment. Examples: if a 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.
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 Qther 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
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GA WIC PROCEDURES MANUAL FY '97

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 Motor-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.

4.

Writing and updating the biennial nutrition education plan.

5.

Planning for classes.

6.

Researching/developing/purchasing/distribution of nutrition

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GA WIC PROCEDURES MANUAL FY '97

education materials.

7.

Grant writing for nutrition education activities. Writing a grant for

the purpose ofgetting 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 ofbreastfeeding among participants. This includes salaries and benefits for WIC staff, non-WIC 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.
8. Participating in State and local planning committees dedicat'ed to breastfeeding promotion and support.

9. Other duties directly related to breastfeeding promotion and support, i.e., staff development, breastfeeding workshops.

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GA WIC PROCEDURES MANUAL FY '97

E. Either Administrative or Nutrition Education:

Activities such as telephone time, travel time, staff meetings, and training must be included in the category they support. Prorati.rig may be appropriate for these specific activities, between the categories they support.

NOTE: (1)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 of these categories.

VII. PURCHASING PROCEDURES

A. Equipment (Excluding Medical Equipment)

All equipment purchased solely with WIC funds 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 AD-6.

As a general rule, all items costing over $100.00, or having a life expectancy of three (3) years or more are considered equipment. However, there are some items which do not meet these requirements and are considered equipment.

1. Approval of Purchases

Allowable office equipment (excluding ADP equipment) may only

AD-20

GA WIC PROCEDURES MANUAL FY '97
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 of this 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. If you 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 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
AD-21

GA WIC PROCEDURES MANUAL FY '97
ofthe needed medical equipment, the cost ofthe medical equipment does not exceed the maximum ($5000), and if the 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 administrative 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:
(1) Only medical equipment specifically listed in the WIC regulations, Section 246.12(b) (3) (iii), may be approved for purchase. The list ofequipment includes only centrifuges, spectrophotometers (includes hemoglobinometers), measuring boards, skin fold calipers, scales, and hematofluormeters used for determining eligibility of applicants/participants.
(2) The cost of the medical equipment shall not exceed the $5000 limit established by FNS in accordance with Office ofManagement 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. Ifthe cost of any one (1) 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:
(a) A description of the equipment to be purchased, including the name ofthe manufacturer and the price.
AD-22

GA WIC PROCEDURES MANUAL FY '97
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 of7 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.
Bl\81E~lii1VIi
H~;~!~~t~\!lf.9J~~4Y~{~~j~l:fffl!~h~~;?J'>t4~si11!1.~:.~
.to P.~9.fi~rtx:::~!~9~:::wmt?!~!~~t~~ fo~ge4'::'!9 'tP~WY"~.f:!gt .Prif:
~P!~#!JI!#.@2?
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.
AD-23

GA WIC PROCEDURES MANUAL FY '97
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 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 of Purchases
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.
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GA WIC PROCEDURES MANUAL FY '97
(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.
(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 #541 0 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 WIC 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 ofNutrition 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-I 0 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-25

GA WIC PROCEDURES MANUAL FY '97
G. Prior Approval/Duplication ofWIC Forms
Prior approval must be requested by the District for all forms noted in the current years Procedures Manual which the District envisions reformatting, modifying or developing.
If the District duplicates a State WIC form, (i.e. Notice of Terminationllneligibility/Waiting List Form or Rights and Obligations Form, etc.), the District is responsible for ensuring that these forms contain the exact information contained on the original Procedures Manual form.
H. Rental of Space
Prior approval is not 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 of lessor 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
AD-26

GA WIC PROCEDURES MANUAL FY '97

the State WIC Office approve capital expenditures for the purchase, repair or renovation of buildings.

I. Rearrangement and Alterations of Facilities

1. 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 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 of the WIC Program.

f. 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 fmal 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

AD-27

GA WIC PROCEDURES MANUAL FY '97

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.

J. Inventory

A comPlete PhYsical inventory.of all equiPment .W,..,,,.,n.,.,o.,.,s.,.,e,.,.1,,,U,.,..f,,i."i.t':"::c:,o""s'"t'":.:,.e,,,,,x,,.oc;.e:.:,&:,:,::.1:c<s:::m:::s,:,:

,,"tms$'J:ooa:oo:wru:cl'KWast urchased with WIC funds must be conducted ~;::,:;:;:;.::;::':'::::.;.&..;.;.;.;::.;,,:,.,,,.;:;.;.,,;:;.;.;:;.;.;.;:;.;.;.;.;:::;:<,:.:::,.:,:::;::::;.;p

'

documented on the State Equipment Inventory Form (Attachment AD-12),

and submitted to the State WIC Office no later than September 30 of each

year. This inventory must be completed and submitted, regardless ofwhether

or not equipment was purchased during the year. The staffperson 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 Personal Property Management manual to properly dispose those pieces of equipment 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

AD-28

GA WIC PROCEDURES MANUAL FY '97

information must be documented.

V.III.

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 ofeach 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 pm:_~j~ will be served. The methodology for allocating food funds is descrlbe(fhl the Financial Management Section of the State Plan.

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. Of the 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 ofthe 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 letter ofcreditState Plan item 6.

X.

PROGRAM INCOME

Any revenue generated as a result of administering the WIC Program is considered

AD-29

GA WIC PROCEDURES MANUAL FY '97

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.

SECTION TWO- PROGRAM ADMINISTRATION

I.

RETENTION OF RECORDS

A. Definition ofRecords

Federal regulations state: "Records shall include, but not be limited to, information pertaining to fmancial operations, food delivery system, food instrument issuance and inventory, certification, nutrition education, civil rights and fair hearing procedures" [7CFR 246.25(a)(1)].

State policy memos from the previous year may be destroyed once the new

Procedures Manual has been received, unless otherwise instructed. For

example, F:f.:X:':~96 Policy Memos may be destroyed once the FFY 291,

-'''''~''''''' ~Y"

..... ~,

Procedures Manual has been received.

B. Records and Reports

The Office oflnspector General has been given total access to WIC Program Records since that Office has overall authority and responsibility for the e?Camination of the Food Nutrition Service Program. The WIC Certification file isJ?.~(2fl1J:l~ documentation for determining food cost charge. Therefore, certificationrecords 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 access to the medical record or other documentation is not made available, a claim will result against the State Agency.

C. Retention Schedule

1. The following documents must be retained for five (5) years, as stated in the DHR Record Retention Policy, issued November 12, 1986:

(1) WIC Assessment/Certification Forms

AD-30

GA WIC PROCEDURES MANUAL FY '97

(2) Diet Histories (3) Growth Charts/Weight Gain Grids

2. The following documents must be retained for three (3) years plus the 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) Fair hearing and civil rights complaints and all related
documentation (IO) Federal, State, District, County Audit reports (II) Copies of manual vouchers

3. The following documents must be retained for one (1) year plus the current year:

Waiting List (Se~f4;::J:]XWJJ
. . X81J9[~:P:~~~~r~~....
4. The following documents may be destroyed after the required correction, verification, and reconciliation has been completed: (I) Dual Participation Report* (2) Cumulative Unmatched Redemptions Part I* (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) Canceled food instruments

*

The original copy of these reports with their m~ual

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

AD-3I

GA WIC PROCEDURES MANUAL FY '97

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:

a. Monthly Reconciliation - Enrollment Cycle

1.

Alphabetic Master File Listing

2.

Critical Error Report

3.

Enrollee Income by Household Size

4.

Grady Hospital Enrollee Distribution

5.

Medicaid-Enrollee Income by Household Size

6.

Medicaid-Percentage of Poverty Income by Type and

Age Categories

7.

Medicaid-Priority Counts by Percentage by Poverty

Income Level

8.

Numeric Master File Listing

9.

Percentage of Poverty Level Income Level by Type

and Age Categories

10.

Priority Counts by Percentage of Poverty Income

Level

11.

Trimester Analysis Report

12.

Unduplicated Participation Report State Fiscal Year

13.

Unduplicated Participation Report Federal Fiscal Year

14.

Waiting List Report

15.

WIC Status (Type) by Reason Certified

b. Monthly Reconciliation

1.

Bank Exception Report

2.

Bank Listing

3.

Closeout Reconciliation Report

4.

Cumulative Unmatched Redemptions Over 30 Days-

Part 1

5.

Cumulative Unmatched Redemption Over 30 Days

Based on Certification-Part 2

6.

DU/Clinic Compliance Summary (Cone. Pwdr. RTF)

7.

DU/County Compliance Summary (Cone. Pwdr.

RTF)

8.

Dual Participation Report-Part 1

9.

Ethnic (Enrollment and) Participation by Priority

Issue. 30 Day and Closeout

10.

Ethnic Participation Summary

AD-32

GA WIC PROCEDURES MANUAL FY '97

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 (Cone. Pwdr. RTF)

16.

Infant Rebate County Summary

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

AD -33

GA WIC PROCEDURES MANUAL FY '97

II.

WIC ACRONYM AND LOGO

A. Authority

The acronym "WIC" was registered with the U.S. Patent and Trademark Office January 1, 1991. The WIC logo a stylized representation of a woman holding an infant in her anns 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 CFR Part 246.

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 is reserved for the official use of national, 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 ofpossible use ofthe 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 Organization, the 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

AD-34

GA WIC PROCEDURES MANUAL FY '97

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 Federallaw, 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.

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 any uses ofthe WIC acronym or logo; and any uses that are considered inappropriate shall be discontinued. Requestfor use ofthe WICAcronym or Logo must be made in writing along with copy/sample of the 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.

III.

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-35

GA WIC PROCEDURES MANUAL FY '97 CONFIDENTIALITY
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AD-36

GA WIC PROCEDURES MANUAL FY '97
jordeliverirfg th~~rat~sefi!!IJ!!fJl:fij)f}ftis(rtf?fitioiJ;:rtrr}~9J!Ying'iT?i13T:'l~!f:
~otftmlftzJqatifj]J...i ~~tjf,c!l)') ;{f?'t/!/J1!J[(:~$; .. ZILyqfi., .f.ti:!)!~:.:,:t~~f:~~q ,/!Jl~
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!P:~d~!~prev~ttt.bre!lCP. ofcqpfi~en#@.D'ktll.~J@'~or~aW!Qft2~1:il~~~#tP*~ ~!.~~tiqrt!J:i. ss~ehl.fj.g'fuid~~le~@~lggj!a~!~:yg!}tftf.~!5\\Y~:;!:<f!ll$:~-v~:-~~~Q
~i1~~i~=~~~:~:~;i~it~;.~~i='iij~~t~:!!ii.~~~;=;~~~~~~~
~}Yle(:fg~~J>I~ gfth~;:~striet~o~;m:"<#~9H?~~-;Qfpatient ~~~!fciotf.
. :J'ns::to1f,q~g)4cti.ons step~ m:us~"8p~::~~9Ti.n fSt~et t9i:fJ!~~~ . p~qip~
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4.... It~;pot#~tial;yg~tffite~~-a9.~~~~9Ei!RP~!l!<>. ~-'~:go<>.CJ:~~~J~,f91!<;~~!~g o-:. ifgc:)nnagg.n~t:ifict~;:tijf~:.m~Y'l?~i2tfletfactiv!!~~~.~t~en#.~2P;9@: ~tr~tii!Jtl.f~t-~t?.m<!P:9r4isl~~~g~.s~~~-!<frparq~~p~~;iw9~tl9~~
;wJQ.~~@latioris:aonotproVidefgrf.t:f(ff#qfi.~,~~fimimd.rppb~~filepf~~9J.[~
ofeircum.stances; The WICf'otidJNtcka.ges ar'designedt<.fbc6rtsili:Iig.\Yi~;'~ ~is~t;i~<I'tifue li~~4'{wh~!'I>Wti~iP.j~: ~~: ~peffencigj ti#~e~ .gf:9~~fti'~~
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AD-37

GA WIC PROCEDURES MANUAL FY '97

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AD-38

GA WIC PROCEDURES MANUAL FY '97

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AD-39

GA WIC PROCEDURES MANUAL FY '97
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AD-40

GA WIC PROCEDURES MANUAL FY '97

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AD-41

GA WIC PROCEDURES MANUAL FY '97 AD-42

GA WIC PROCEDURES MANUAL FY '97 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. Step 3.

$(A) + $(B) + $(C) + $(D)... = $$

$$

=

#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 1 must be non-WIC 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 WIC 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 1. Salary x Fringe Benefit Rate= F

Fringe benefits are a percentage of the employee's salary. 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-43

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-I cont'd

Step 3. Yearly Salary/hours per year= Hourly Rate Monthly Salary/hours per month = Hourly Rate

'***

The source for this data are the ADP Contractor reports. "#assessments" is the total number of assessments performed during the time study period. "# participants" is the number of participants reported for the time study period.

2. FULL-TIME EQUIVALENTS (FTE's)

The following may be used to compute FTE's:

Step 1. individual's time worked

performing WIC duties x 100% =%of time 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-44

GA WIC PROCEDURES MANUAL FY '97

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 R.N.'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 Support (Non-Medical Personnel Only): (Not to be used by M.D.'s, Midlevel Practitioners, and Nurses- Medical). Include time spent providing clinicaVclerical support services to medical staff above. (Examples: Time spent by Health Services Technicians in clinical interviewing, weighing patients, setting up the clinic, etc.)

E. Laborato:ry 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 clericaVtyping work not directly supportive of Health Care Services.

I. Non-Family Planning/Non-WIC: Time spent in functions not related to Family Planning or WIC.

J. Holidays. Annual/Sick Leave: Use to record any of time in these activities during time study.

AD-45

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-2 cont'd

K. WIC Administration: Time study activities, grant writing, preparation and maintenance of 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 fmancial services and clerical support. Planning and training in administrative and ADP areas and audit tracking, hatching and mailing Motor-Voter Registration Applications as well as maintaining a file of Motor-Voter declinations.

L. Client Services: Income screening, completion of WIC 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 ofWIC 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 Motor-Voter registrations and declinations.

M. WIC 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, Lor M).

AD-46

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-3

WIC TIME STUDY DATA COLLECTION FORM

MON TUE WED TBR FRI 7:30AM 7:46AM 8:00AM 8:16AM 8:30AM 8:46AM 9:00AM 9:16AM 9:30AM 9:46AM I O:OOAM !0:16AM !0:30AM !0:46AM ll:OOAM !1:16AM 11:30AM 11:46AM !2:00PM !2:16PM !2:30PM !2:46PM 1:00PM 1:16PM 1:30PM 1:46PM 2:00PM 2:16PM 2:30PM 2:46PM 3:00PM 3:16PM 3:30PM 3:46PM 4:00PM 4:16PM 4:30PM 4:46PM 5:00PM,

SUMMARY
CODE MON TUE WED THU FRI A B
c
D E F

TOTAL

EMPLOYEENAME: ____________________________
TITLE: ___________________________
CLTIUC/COUNTY: ___________________________
WEEK WORKED: ----------------------------
REFER TO DEFINITIONS FOR COMPLETE LISTING
A. WIC ADMUUSTRATION: WIC Program management duties i.e. computer system management/maintenance, time study activities, grant writing, preparation and maintenance of program management reports, overseeing food instrument accountability and reconciliation; iJScal management duties i.e., office management, record keeping, personnel actions, leave records; vendor management activities, outreach activities. "Planning, training in Administrative and ADP areas and audit tracking." Batching and mailing Motor-Voter Registration Applications as well as maintaining a file of Motor-Voter declinations.
B. CLIENT SERVICES: Income screening, completion of WIC assessment/certification forms, beight, weight, hematocrit, plotting growth charts/weight gain grids, referrals, record retrieval and filing, voucher issuance process, explanation ofWIC-approved foods, dietary recall and assessment (for tbe purpose of determining eligibility). Receiving /resolving complaints, delivery food/other services, program coordination, completing surveys/studies. Time spent assisting clients with Motor-Voter registration and declinations.
C. WIC NUTRITION EDUCATION: Nutrition education given during certification, WIC follow-up nutrition education (secondary contacts). Includes planning and documentation of time for nutrition education (not for determining eligibility), developing materials (includes research and procurement) and nutrition education services. Charge Nutritional Education given to EPSDT or Family Planning.
D. BREASTFEEDING ACTIVITIES: Proll!otion and support of breastfeeding. Individual contacts, planning documentation and developing materials for supporting the breastfeeding mother, planning/conducting classes, monitoring promotion activities attend meetings.
E. NON-WIC
F. ANNUAL LEAVE. SICK LEAVE, OR HOLIDAY:
SIGNATURE: ________________________________
DATE: ________________________________

AD-47

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-4

WIC/FAMILY PLANNING TIME STUDY DATA COLLECTION FORM

MON TUE WED THR FRI 7:30AM 7:46AM 8:00AM 8:16AM 8:30AM 8:46AM 9:00AM 9:16AM 9:30AM 9:46AM !O:OOAM !0:16AM !0:30AM !0:46AM ll:OOAM 11:16AM 11:30AM 11:46AM !2:00PM !2:16PM !2:30PM !2:46PM 1:00PM 1:16PM 1:30PM 1:46PM 2:00PM
2:16PM
2:30PM
2:46PM
3:00PM
3:16PM
3:30PM
3:46PM

EMPLOYEENAME: _ _ _ _ _ _ _ _ _ _ _ _ _ ___
TniE: _____________________
CLllUC/COUNTY: -----------------------WEEK WORKED: - - - - - - - - - - - - - - - - -
INSTRUCTIONS
Record time every 15 minutes. Record the activity you are doing at the end of each 15 minute period.
Entire day/week are to be acconnted for. Time spent in recording information in patient record is to be charged as a part of each activity. Time spent in recording results of physical exam will be coded by the title of the provider (Codes A-D).

CODE A B
c
D E F G H I J K L M N TOTAL

SUMMARY

TOTAL

4:00PM 4:16PM

SIGNATURE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

4:30PM 4:46PM

DATE: ----------------------------------------

5:00PM

AD-48

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-5

FFY: _ __

TIME STUDY DATE: DISTRICT/UNIT:
DATE SENT TO SWO:

SIGNATURE:----

(1) NAME

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11) (12)

(13)

(14)

(15) (16)

TITLE

MONTHLY SALARY

TOTAL TOTAL %

TIME INCRE

ADMIN ACT.

ADMIN

TOcTsAL ACT.

c% s

TOTAL % TOTAL % COST COST

N.E. N.E. B.F. B.F. OF

OF

ACT.

ACT.

ADMIN CLIENT

COST COST OF OF N.E. B.F.

SVC

*INCREMENTS- TOTAL NUMBER OF UNITS CODED
1 =EMPLOYEE'S NAME 2 =EMPLOYEE'S JOB TITLEIPOSmON 3 =EMPLOYEE'S MONTHLY SALARY 4=TOTAL TIME INCREMENTS* 5 =TOTAL ADMINISTRATIVE ACTIVITIES 6 =PERCENTAGE OF ADMINISTRATIVE ACTIVITIES 7 =TOTAL CLIENT SERVICE ACTIVITIES 8 =PERCENTAGE OF CLIENT SERVICE ACTIVITIES

9 =TOTAL NUTRITION EDUCATION ACTIVITIES 10 =PERCENTAGE OF NUTRITION EDUCATION ACTIVITIES 11 =TOTAL BREASTFEEDING ACTIVITIES 12 =PERCENTAGE OF BREASTFEEDING ACTIVITIES 13 =COST OF ADMINISTRATIVE ACTIVITIES 14 =COST OF CLIENT SERVICE ACTIVITIES 15 =COST OF NUTRITION EDUCATION ACTIVITIES 16 =COST OF BREASTFEEDING ACTIVITIES

AD-49

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-6

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

I. Description ofthe ADP equipment to be purchased and the anticipated cost. Ifthe cost is not to be borne solel:Y 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 of the 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 of how 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-50

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-7

MEMORANDUM OF UNDERSTANDING BETWEEN
STATE AND LOCAL AGENCIES FOR
THE SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC)

This provider agreement is made pursuant to the Georgia Department of Human Resources Administrative Policy and Procedures Manual, Part II A.l., Administration of Grants and USDA/FNS 7 CFR 246.6, Agreements with Local Agencies. This agreement is between the Georgia Department of Human Resources, Division of Public Health and the District Health Program (hereinafter referred to as the Local Agency) named on page IV of this agreement. This agreement is made effective the first day of October, !19516 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-

Counties Policies for administration of funds.

2.

To collect data as required by USDA and State regulations and requests to insure confidentiality of all such

information in accordance with the State's confidentiality requirements.

3.

To further abide and comply with USDA program regulations 7 CFR 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, breastfeeding Ji.f:.'l!~f:!~~tyu:,e~expenses of the WIC

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 WJC 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 pIfr~ manuals, forms, and !Jf:!f.IT.~i:J.:'qP.Qr;i materials required for operation of the WJC

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 WJC responsibilities: and to provide

necessary facilities, equipment and training to perform WIC assessment and certification procedures. WJC

AD-51

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-7 cont'd

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.

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 Agreement with 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 lmmunization/WIC 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 Agency.

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, co_rrective 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 onsite 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

AD-52

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-7 cont'd

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 assessments of program accomplishments in accordance with WIC 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.

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 Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and all requirements imposed by the regulations of the Department of Agriculture (7 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 activity for which the program applicant received Federal financial assistance from the Department; and hereby gives assurance that it will immediately take 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, to 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 State 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.

19. To comply with program regulations that ensure program accessibility for participants and applicants identified as special populations. Including but not limited to communication capabilities for ~on-English speaking individuals and vision and hearing impaired individuals, and facility accessibility for persons with disabilities. All facilities where WIC related services are provided must be accessible from the outside and on the inside. Bilingual staff, volunteers, and translation resources should be available to serve nonEnglish speaking clients as appropriate.

AD-53

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-7 cont' d

20. To comply with basic requirements for local agency participation in the development of the State Plan consistent with WIC 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.

By accepting this assurance, the program applicant agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of Title VI and to permit authorized USDA personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Agriculture, Food and Nutrition 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 receives 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 representative
DATE: _ __

District Health Director or the designated representative acting collectively for the Counties in District_, Unit_
DATE: _ __

AD-54

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-8

CONTRACT BUDGET

~X _______________

CONTRACT BUDGET

Contract Period _ _ _ _ _ _ _ _ _ to - - - - - - - - - -

A.

Personal Services

Salaries

Fringe Benefits

Other

B.

Supplies

C.

Printing

D.

Equipment

Office

Facility

E.

Contractual

Client Services

Per Diem & Fees

Consultants

F.

Travel*

G.

Client Transportation

H.

Space

Rent

Utilities

I.

Audit

J.

Insurance/Bonding

K.

Other (specify)

BUDGET GRAND TOTAL Narrative Justification: * Travel Reimbursement to contractor from funds provided under this contract shall not exceed the rates established in the Statewide Travel Regulations.
AD-55

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-9

MONTHLY EXPENDITURE REPORT

CCOONNTTRRAACCffONRUNMABMERE:: - - - - - - - - - - - - -

]MONTHLY ]QUARTERLY
I OTHER----------

CUMULATIVE CONTRACf EXPENDITURE REPORT PRIOR CUMULATIVE

TYPE EXPENSE
A. Personal Services Salaries Fringe Benefits Other
B. Supplies
C. Printing
D. Equipment Offices Facility
E. Contractual Client Services Per Diem & Fees Consultants
F. Travel
G. Client Transportation
H. Space
Rent Utilities
L Audit
J. Insurance/Bonding
K. Other (Specify)

APPROVED BUDGET AMOUNT

PRIOR CUMULATIVE CONTRACf EXPENDITURES

MONTH OF
EXPENDITUREini;'<"s"'iF"'O;w;R;-;RE;;;;;IMB~.

BALANCE

TOTALS *Payment Amount
I, the undersigned, certify that the Expenditures reported have been made for Program accomplishments within the approved budgeted items:

Signed Date Submitted to DBR Division: - - - - - - - - - - - - - -

AD-56

GA WIC PROCEDURE~ MANUAL FY '97
Date Received by DHR Division: - - - - - - - - - Approved for Payment:

Attachment AD-I 0

DHR Division Budget Officer

WIC FORMS AVAILABLE IN CENTRAL SUPPLY

Contact:

Cindy Woods

(404) 657-2900 or GIST 294-2900

FORM NAME

FORM#

I.

Georgia D~artment of Human Resources

Division of-public Health!WIC Program

I.D. Card - Box/500 . . . . . . . . . . . . . . . . . . . (Spanish) #3793 (English)#3769 (Rev. 8-88)

2.

Georgia D~artment of Human Resources

Division of-public Health!WIC Program

Rights and Obligations - Pad/100 ....... (English) #3768- (Spanish) #3766 (Rev. 6-91)

3.

Georgia D~artment of Human Resources

Division of-:rublic Health!WIC Program

WIC Assessment/Certification Form

Women - Pad/100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . #3296 (Rev. 8-89)

4.

Georgia D~artment of Human Resources

Division of-:rublic Health!WIC Program

WIC Assessment/Certification Form

Infants - Pad/100 .......................................... #3299 (Rev. 8-89)

5.

Georgia D~artment of Human Resources

DivisiOn of-public Health!WIC Program

WIC Assessment/Certification Form

Children - Pad/I 00 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . #3285 (Rev. 8-89)

6.

Georgia D~artment of Human Resources

Diviswn of-:rublic Health!WIC Program

Batch Control Form - Pad/100 .............................. #3762 (Rev. 11-89)

7.

Georgia D~artment of Human Resources

Divis.wn of}:'1;1blic Health!WI<;:: Program

Invalid PartiCipant ID CorrectiOn Form - Pkg/250 ................. #3763 (Rev.4-86)

8.

Georgia D~Qartment of Human Resources .

Division ofPublic Health!WIC PrQgram

Notice ofTermination!Ineligibility!Waiting List - Pkg/250 (Spanish )#3009 (English)#3293 (Rev. 11-

90)

9.

Georgia D~artment of Human Resources

Diviswp of-:rublic Health!WIC Program

Food List Brochure - Pkg/100 ............................... #3777 (Rev. 10/93)

10.

Georgia D~artment of Human Resources

'

Diviswp of~ublic Health!WIC Program

Food List Stickers - Pkg/250 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . #3778 (Rev. 6/93)

AD-57

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-10 cont'd

11.

Georgia D~artment of Human Resources

Division ofPublic Health!WIC Program

.

.

WIC Outreach Card (Large) ............ (English) #3765- (Spamsh) #3754 (Rev. 7-91)

12.

Gorgia D~artment of Human Resources

Division ofPublic Health!WIC Program

WIC Outreach Card (Small) ............................................ #3752

13.

Georgia D~artment of Human Resources

DivisiOn ofPublic Health!WIC Program

.

.

WIC Outreach Flyer/Poster . . . . . . . . . . . . . . . . . . . . . . (English) #3749- (Spamsh) #3733

14.

Georgia D~artment of Human Resources

Division ofPublic Health!WIC Progr:am

Georgia WIC Resource Referral Gmde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . #3297

AD-58

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-11

NUTRITION MATERIALS AVAILABLE IN CENTRAL SUPPLY

Contact: Kathryn Thompson

(404) 657-2884 or GIST 294-2884

1.

WOMEN

Good Beg_innin_gs (English & Spanish) Building Blood-(Enghsh & Spanish) Your Daily Food Guide ~nglish) Weight Control (English Exercise Away Your Ca ories ~nglish). Guide to Good Eating (l;:nglish & Spanish) Nutrition for the New Mom (En~lish & SI?anish) Breastfeeding Near to the Heart E:qglish & Spanish) Breastfeeding Doesn't Have To e Embarrassmg (English). Breastfeeding Can Make Baby's Father More Lovmg (English) Breastfeeding Can Make Grandmothers More Lovin_g (English) Breastfeeding Can Help You Bond With Baby (English) Breastfeeding Is E~y to Learn (English). Breastfeeding Can Make You Feel Good About Yourself (English) Breastfeeding Can Make Your Family Proud @nglish) Breastfeeding Doesn't Keep You From Doing Wliat You Want (English) Breastfeeding Doesn't Have To Tie You Down ~nglish) Breastfeeding Doesn't Change the Way You Eat (English)

2.

INFANTS

Food For Baby's First Year (English & Spanish) Feeding Your Growing Baby (~nglish & Spanish) Put Your Child To Bed With a Teady Bear (Enghsh & Spanish)

3.

CHILDREN

Food For Children 1-5 ~nglish & Spanish) Trim & Fit Kids ffinglish & Spanish) Good Snacks For Kids WngliSh & Spanish) About Good Nutrition (Eng1ish)

*This list is not inclusive of all available materials. Contact OON for additional items.

AD-59

GA WIC PROCEDURES MANUAL FY '97 EOIDPMENT INVENTORY FORM

Attachment AD-12

WICPROGRAMEQIDPMENT~NTORY
(3 Year Life Expectancy and $100 or Above) HEALTH DISTRICT: - - - - - - - - - - - - - -

INVENTORY NUMBER

DESCRIPTION

SERIAL NUMBER

LOCATION

PURCHASE PRICE

PURCHASE DATE

WICFUNDS EXPENDED

Inventory Completed by: _ _ _ _ _ _ _ _ _ _ _ _ _ _Date:_ _ __ AD-60

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-13

System Maintenance Indicator Technical Assistance Procedures
I. The designated State staff will contact the WIC Coordinator whose District's System Maintenance Indicator(s) indicates action needs to be taken. The purpose of the phone call is to discuss the indicators and make suggestions.
2. Within twenty (20) days of the telephone call, the Coordinator must submit a written report which includes the following:
a. The possible reason(s) for the non-compliant rate.
b. Plan for correction (including objective(s)), action steps, milestone timeframes, monitoring plan, re-evaluation plan).
The Coordinator will have (120) days to improve the non-participation rate and any other outstanding indicator.
3. If the rate has not improved by the end of the (120) day action plan period, State staff will provide on-site technical assistance.
4. The SMI!fechnical Assistance Summary Report will be used to document District response to the SMI rates. (Attachment AD-15)
When a technical assistance visit is required, the following procedures will be followed:
a. State staff will 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 the (120) day action plan period.
b. Training will be district or clinic specific at the discretion of the WIC Coordinator and designated State staff.

AD-61

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-14

GEORGIA DEPARTMENT OF HUMAN RESOURCES STATE WIC PROGRAM
SYSTEM MAINTENANCE INDICATORffECHNICAL ASSISTANCE REPORT FFY '97

SMI NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _,(I.E. NON-PARTICIPATION)
DATE OF CONSULTATION: _ (BYPHONEORSITE~sm, ____________________________

STATESTAFF: -----------------------------------------------DATE REPORT DUE TO STATE: - - - - - - - - - - - DISTRICT: - - - - - - - - - DISTRICT REPORT DATE: - - - - - DISTRICT STAFF NAME: - - - - - - - - - - - - - - - - - 1. Reason for outstanding rate: -----------------------------

2. Which clinics are involved: (Clinic #'s)

3. Plan of action taken: - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

4.

Is Technical Assistance requested? Yes__

No__

Reportsubmittedby: -------------------------

AD-62

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-15

STATE WIC OFFICE State Report
System Maintenance lndicatorffechnical Assistance Summary Report

- - District

- - Unit

Coordinator's Name: - - - - - - - - - - - -

Date call was made to District: - - - - - - - - - - - - - - - - - - - - -

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

Actual date report received: - - - - - - - - - - - - - - - - - - - - - -

Rate at time of phone call: - - - - - - - - - - - - - - - - - - - - -

Rate (120) days from the phone call: - - - - - - - - - - - - - - -

Is a Technical Assistance visit needed? Yes

No,_ _

If yes, when is the date for the visit? - - - - - - - - - - - - - - - - - The visit will cover:

DistricUCiinic: - - - - - - - - - - - - - -

DistricUCiinic: - - - - - - - - - - - - - -

DistricUCiinic: - - - - - - - - - - - - - -

DistricUCiinic: - - - - - - - - - - - - - -

DistricUCiinic: - - - - - - - - - - - - - -

AD~ 63

GA WIC PROCEDURES MANUAL FY '97

Attachment AD-16

Agreement for Disclosure of Information Betw-een the Georgia Division of Public Health,
WIC Program and-----------

THIS AGREEMENT is entered into between the Georgia Division ofPublic Health for the Special Supplemental Nutrition Program for Women, Infants, and Children, hereinafter referred to as WIC, a n d - - - - - - - - - - - - - - ' hereinafter referred to as the Receiving Organization.

This agreement is entered into by both parties in accordance with Federal Regulation 7 CFR 246.26(d) which allows for the disclosure of specific WIC applicant and participant information (current and historical) for the purpose of(l) establishing the eligibility ofthe WIC applicant or participants for health or public assistance program; and (2) conducting outreach to WIC applicants and participants. This agreement will be in effect for an indefinite period of time or until a written request is submitted by either agency to modify or cancel it.

THE PARTIES AGREE:

A. 1.

WIC will provide the following applicant or participant information to the Receiving Organization as needed: information on the WIC Assessment/Certification Form or in the computer system including, but not limited to, name, address, phone number, social security number, ethnic origin, and birthdate;

2.

Medical data will not be provided;

B. Receiving Organization agrees:

1.

That the WIC Program information may be used only for the purpose of establishing the eligibility ofWIC

applicants and participants for health or welfare programs administered by the Receiving Organization, and for

the purpose of conducting outreach to WIC applicants and participants for such programs.

2.

The Receiving Organization agrees and assures that it will not disclose information provided by WIC under

this agreement to a third party and that it will resist other efforts to obtain this information. It further assures

that it will restrict the use or disclosure of WIC program information according to WIC guidelines, including

7 CFR 246.26(d).

.

Patrick J. Meehan, Director Division ofPublic Health

Director

Date._ _ _ _ _ _ _ __

Receiving Organization Date._ _ _ _ _ _ _ _ __

AD-64

GA WIC PROCEDURES MANUAL FY '97 Release of Information Form

Attachment AD-17

--

. .D.al ' lllrth



lF AVAIL\BL.E:

AUTHORIZATION FOR RELEASE OF 1!-!F'OR.MAnON

I hereby request and authorize:

to obtain from:

(Ad4tt")

(A~cltt")
the following type(s) of information from my record~. (&nd any 5pecific portion thereof):

for the purp~ of:
All information I h~r~by author/:~ to b~ obtain~d from this azency will b~ held strlr confidential and cannot be released by the recipient without my written cons~nt. I unr sland that this authorization will remain in effect for:
0 nlnuy (9~) days unless I specify an earlier explra;lon date he~:----.,=~-- <Dt>
O 011e (1) year. 0 the period ne~ssary to ccmplite all trafl.S4ctio1lS 011 accounts related to servlcu prov1
rome. I understand that unless otherwi.st limited by $tau or federal regu/4tion, and trctpt to extent that action has been taMn 'Which was based on mY consent, I mtZY withdraw thls con at any time.

(fitI& ot JOt,IIOII&lilp
to CUttll)

(li-.natute of l'art~t Of A11dionua
ll.t~ftMilLitl~, Vtflltt eppllceblt)

USE THIS SPACE ONLY IF CUENT WITHDR.AWS CONSEhT

(i~"atwt of Clio"')

AD-65

GA WIC PROCEDURES MANUAL FY '97

I. II. III.
IV. V. VI. VII. VIII. IX.
X. XI. XII. XIII. XIV. XV. XVI.

.TABLE OF CONTENTS Page
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VN-1 Vendor Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VN-1 EnrollmentofNewVendors ......................................... VN-1 A. .APPJis4ti~ij B~'ltiY:~W~il~ of Vendors ............................... VN-1 B. Approval Criteria for Vendors ..................................... VN-4 C. Authorization/Reauthorization ..................................... VN-5 Vendor Stamp ..................................................... VN-5 Termination ...................................................... VN-5 Vendor Agreements ................................................ VN-5 Vendor Training ................................................... VN-7 Vendor Materials .................................................. VN-9 Monitoring ...................................................... VN-10 A. Vendor Monitoring Procedures ................................... VN-10 B. Local Agency Monitoring Procedures ............................. VN-11 Compliance Investigations .......................................... VN-12 Vendor Sanctions ................................................. VN-13 ?91P:Pl~i,i~sAg~~t}'#~q~[ ........................................ VN-13 Terminations/Disqualifications ...................................... VN-14 Vendor Fair Hearing Procedures ..................................... VN-16 High Risk Vendor Identification ..................................... VN-17 Minimum Inventory Requirements Waiver ............................. VN-18

GA WIC PROCEDURES MANUAL FY '97
Attachments: VN-1 ' Vendor Application Booklet ........................................ VN-19 VN-2 Application for Vendor Certification .................................. VN-36 VN-3 Vendor Input/Registration Document ................................. VN-38 VN-4 Vendor Agreement ................................................ VN-39 VN-5 Military Commissary Agreement ..................................... VN-42 VN-6 Pharmacy Agreement .............................................. VN-43 VN-7 Vendor Training Checklist .......................................... VN-46 VN-8 Vendor Training Information Form ................................... VN-47 VN-9 Vendor Training Sign-In Sheet ...................................... VN-48 VN-10 Vendor Handbook ................................................ VN-49 VN-11 Cashier Training Pamphlet .......................................... VN-69 VN-12 Return Voucher Payment Log ....................................... VN-75 VN-13 Post Vendor Training Evaluation ..................................... VN-76 VN-14 Vendor Review Form (includes Price Report List) ....................... VN-78 VN-15 Vendor Review Form Instructions .................................... VN-82 VN-16 Incident/Complaint Form ........................................... VN-86 VN-17 Vendor Profile Report ............................................. VN-87 VN-18 Vendor Application Booklet Cover Letter .............................. VN-88
VN-19 ~~4ti2tf~Y~f~p:i . . ............................ VN-89
VN-20 Pharmacy Handbook .............................................. VN-90
VN-21 Goft@it;f.{qq~*dlifu .............................................. VN-111 VN-22 Y.e.tlCiof$lfJfaining~igP:~:Iil::~he.~t .................................. VN-112
>.................................................... ,..... "' .....:<:.. ..

GA WIC PROCEDURES MANUAL FY '97
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 of the local agency to designate one or m()re pe()ple 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.
III. ENROLLMENT OF NEW VENDORS
A. Application. Requie!ll~fits of Vendors
1. Any merchant expressing an interest in participating in the WIC Program will be sent a Vendor Application Booklet (Attachment VN-1 ), including an Application for Vendor Certification (Attachment VN-2), the WIGApproved F()od Patnphlet (Form #3777).>~tdpieVendor RevieW Form (:f\.ttachme11t YN,.14). Applications
are accepted ~ach;we~kday and should be returned tq the Local Agency to be pro~essed Cl}{)tig :Witll the Ve11dorReVie"".' ForiD..that is pompletedb)' Jhey~11dor.
The''appl!~~tiot) pf6cess. takes,45working gays .fof comp~etiorL. Therefore, yefic16rs \,yhQ Wish . >to receive .; apprt>:\Tal or denial. >regardit1g WIC veiiddf
authorization wustsubmit a completed WIC applic~tiohform45:\V()rki11g,,day$
PtiC>no s~()fe;.<:>pei@tg pr c~ge:ofownershi:P~?All retfiil vendors Wiltbe subjeCt
t()'~~,~~~appli(5ttion ptocess>.wrc vouehers'ml!st not be}tccepted:PY
v~ndor appli~an((}t1iin~fthe application process~
Local Agencies may consider using Attachment VN-18, which is a typical form letter that should accompany the application packet.
2. Applicatio]:},:process~
lst"'~th w()tldi.tgday:
The Local Agency will forward the Vendor Application for Certificatio11 with the Vendor Review Form _(vendor's self review) to the State .WIC
VN -1

GA WIC PROCEDURES MANUAL FY '97

Office within 5 working days.

6th - 20th workillg day:

The State Agency will review the above documents withinTS\yorkiligday~

for the following:

. ..... .. ...

a. The appli~ationw:ill be reviewed fot~ccuracy and a1JI:!:~grouri~ chef:k
will be conducted~
to b. The vendor's prices will be analy~e<i .ascertain ifpJi:c~s~chargedfot
WIC approved foods nieetthe state pfic~g Standards~ c. The vendor's DepartmentofAg:gi~t1lttlt,e ~d Fooq'~t~p P~()~
eligibility will be verified. d. The State WIC Qffice ~l fax/m@pre~iinip.azy approval hoticeSto!Be
Local Agency;Vvithin this tini~ period.
e. The State WIC.:Office willf~mail'dehiallettersto:::ventlors.and'.the
Local Agency Within this t~e p~ri64. Denied v~IT,~~f.~tnay:bbrr~tj
deficiencies within 35~\\f<?tlci.Iig. <i~ys:of.:P.em~tP a(tJ,y,~J:lgor cg>es'ilt correct the deficiencies \VithinJ5 W<?rJring. days of depihl, a newyeilq('#
application must be re.;,subniitted'tg th~Ji()cal:Agegy,

21st - 35th working day:
Ypon reCeip~ of"fl.les~te WIC. Office ptelinririary-:approv~t.~f::.~:.ven4p.~!' fu~ Local Agency wi1Lc6nducran on~site>niohitorlng~visit~f!rhe sti?i~.ai!4
tentatively >schedule... vendor training for :~ new . .$f:ot~ . pet5()Ii:l'fel
(owners/manager/cashiers/etc.) withihas:Wotkii1g.4~:tYS .The following pro~$es will.take pla~~dtling th~:Loca} Ag~gcy revie'f:
\f! a. Non~perish~.ble,items must be~in the,yendofsstore 'witbiri.J5 days prior
to store. openiJig. or chmge of.6Wnership.~i,specifi~4.dn fue..
application.
b. Thus. the L?cal Agency must b~ aijO:\Vedto condu~!.an.:u.n~nn~ubC(!(.i
on-site .1llol1i!8Jing visit.<mytM#~'.~~$-~ l?0~a:?P~riod;_4~~
standard busin~$s;hour~ (8aii1 ~ ?J?PiJ~
c. The Local Agehty will fa.X al14 fii~l th Ye1:1~or Rev~e"Y: Fol#J::wt~
approval Visit ()~tdome)to the Stat~~cbffi.ce Witl#fltbis furi~ perg~4;

36th - 40th working day: The State WIC Office will render .appt<>val or.: ~ehial o:(: the ynd6r
application. a. If a vendor is approved the WIC authori~tiolistamp will be fot'Watd.<:1
to the Local Agency with a. copy.pfthe af>tJlication and the'ye~4tit registration fonn. Therefore, th Local Agency can ptoceed..Wim

VN-2

GA WIC PROCEDURES MANUAL FY '97

vendor training as scheduled and the owi1er or manager who is legm~y
responsible for the stqte can sigh the WICVendor Agreement/Contr-~tt.

b. If a vendor is denied the State'WIC Office Will fax.and mail thenotice
to the Local Agency Within five working days. Likewise, the St~te
WICOffice will mail the vendor his!herdeliial notice via regula.t~@
within the same time perio&. .The L()c:;tl Agency .Will canc~i.:'@~

tentatively schedUled vendor~gsessiontipon receipt ofthed~piai

notification..< Vendor applic"@ts .ilia)' co~ct defiCiencies Withiti::fs

wotkiilgdaysOfdeiiiai. If~ vendor 'doe~ hot'correct the deficiefii~

'

.. .

. ...

..

:..

'

....

.:.

.

..

..:>. . . '.)..'

within 3?: .Wotkirtg~ days of denial, :ftiev.r vendor application must b tt:}-

sub:rfiittecJ.to theLocai Agency.

41sfo;;45th.'~'orkin:gda.y:
New vendortriliniiig may-takeplace iftrairii.tlg Clid not occnr previously; _W
addition, the vendor ownerll11an(lger will sign the V~ft96t
.A.,greeft:tent19()n1factandreceive his/her YJIC authoriZation. stamp duril1g mt'~
time.peri:Od:

Once store 6'lyner/manger 'receives .the trairimg packet they wili~J:j~ respo:ri.siblefo:ttra.in1D.g store employees and~ma.y designate employs to cofi~\lCf;}'iJl-stote trairifug... \ Documentation of who the stQ,te oWD.er/managef designated to provide framing shall be substantiate4;;y. writing to the District WIC Otpce staff via certified ,mail. ~tatf-1).0.~ DistticfWICst~ff are. available to provide su)?sequent training.

46th --_75th day: The Local Agency -will conduct a new vendor on-'site monitoring review wit{liil. 30 daysa:ft:erWIGVendofauthoriZatiolJ.~ Therefore, the store riil.lSt meet the \M.fC
Wi miillriibin 'fuventoty reqUirements oriperishable; and nori~perish~ble
approved food items upon authorization and arty-time the store is opn. for
business.
3. The State WIC Office has the authority to deny a yendor applicaiJ.t fro WIP
Program participation, if the applicant 'previously was an ~n.lthor!~d
vendor/manager that volul1tarily withdrew froIIi WICProgram participationW:!til
oneormoretypesofthe following derogatory standings:

-High risk according to the state agencis high risk indicator (s) - Abusive by state agency's outlined sanctions -Food Stamp Program disqualification

VN -3

GA WIC PROCEDURES MANUAL FY '97
B. Approval Criteria for Vendors
Approval by the State WIC Office for vendors applying for WIC Program participation will be based on the selection criteria listed in the Vendor Application Booklet (see Attachment VN-1).
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).

'~ixed.Stotes:DareWIG;authori.Zed:ifn:rnobile'Stores:Which trarisa.etWIGvouchers~ili
~~(tii@ti$i~~:::~ii~l~$~~~:r~tidici~~i: .1bl'P91iSY:i~~in~8es~~ ~:~t~$i~!it@i~~!

fiXeasurefu:i.d'i~~~ppqt;t:~Sfpyth~.Departrnen.t. . of.tJ:1fiti~Resc,}U:c~$g~~~~!9i1.f.ii*$

well:asnivisionof,Public;Health adrriinisttators~

.: .:..: .. '- ,,.,.,.~-:;;.:-:;:-:;:;;:::. ."...:.::.~ ~:,:;~:-::::;:::;::;.;.,.~..:;.;::~:::.:.:::-::::. .... . . ' .... .. : ..>...:::-~-:-:-:>

.;.:-. .. . l .

.

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 of store. 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 not complete the vendor type when completing an inputform (Attachment VN-3).

VN-4

GA WIC PROCEDURES MANUAL FY '97

The following is a list of vendor P~r group codes, square footage, and vendor type:

?eer Group Code/ Vendor Type Code

Square Footage

Vendor Type

1

0-5,000

Small Fixed Location

2

5,001- 10,000

Average Fixed Location

3

10,001 - 15,000

Medium Fixed Location

4

15,001 ORMORE

Chain Fixed Location

5

N.A.

Commissary Fixed Loc.

6

N.A.

Pharmacy Fixed Location

7

15,001 ORMORE

Independent Large

Fixed Location

C. Authorization and Reauthorization

Authorization and reauthorization, including 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. VENDORSTAMP

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 pa:y:~o~ and replace lost or damaged vendor stamps. When a replacement or additional stamp is issued to a vendor, the State WIC Office should be notified.

V. TERMINATION

When a store is terminated for any reason, the local agency must submit a Vendor Input/Registration form to the ADP Contractor terminating the vendor. The vendor stamp must be returned to the State WIC Office with a copy of the Vendor Input/Registration form. If the stamp is not retrievable, submit the Vendor Input/Registration form to the State WIC Office with a statement noting the reason why the stamp is not being returned.

VI. 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 vendor.

VN-5

GA WIC PROCEDURES MANUAL FY '97
The contract year for a Vendor Agreement is October 1 through September 30. A new Vendor Agreement must be signed by October 1 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.
Ver.i..d. .<...J..i..s..W. .. .h.q...;.'.(..f.(. )...1.. 1..o..t..s.j...g.t.1...a. .n.e.w......V.. eii.d..o..t.A. g.re. e.lt. 1.e.n...t....\.Y....i..1...:.bl.l.it.h..e..}IT'e.ci.f.i. ed...tim... e. ;ILe...i.i.odm....i.,t'J!';
r~appty:for~~G ittl:tli911~t!~n.
Military commissaries must sign the Military Commissary Agreement (Attachment VN-5).
Pharmacies are exempt from the minimum inventory requirements. Pharmacies must sign a Pharmacy Agreement (Attachment VN-6).
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 of the Vendor Agreement (new vendors) must 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:
I. 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 not authorized to participate in the WIC Program.
After Vendor Agreements are signed and forwarded to the State WIC Office, within 30 days from receipt, the State WIC Office will submit to each District a list of Vendor Agreement(s) that were not 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 Input/Registration form to the State WIC Office ~~:tJ.:i~@RiR{;}jip-~gr.
VN-6

GA WIC PROCEDURES MANUAL FY '97

Vendor type should not be completed; this field is for State WIC Office use only.

~~Ili)Wizers/tip haizges, an>application forveridoratithorization mustbe completeal?:Y
the)ie'Y Qwn~r~ '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 Page VN-4 for Approval Criteria for Vendors) by the State WIC Office. A new Vendor Agreement must be signed by the new owner.

When a store address changes, the local agency must .submit a copy of the Vendor

Iriplif!Re....gistrationfd. rin.':.to.

th.State

.

.

WIC
.

Office

andtheADP .

contra. Ctor.

WIC vouchers must not be accepted by a new owner dUring the application 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. TheVendorAgreeriierit Il1ust be sigD:~d;andyendor ~tariipnmst be issued pri()f:to/vt:mchers beillg accepted. ,

If the manager who signed th.e ()riginal VendorAgr~emeiit/Cont:rat.iemaillsthe sani~ the

Local A:gencY:' >Will .havethe manager. update the Vendor filt;: 'With.anew Vpdor

'Will A

g

r

e

e

m ... "

pt/C .. ... ...

ontr ..... .. .

a

c
. .

.{. -a.

n

d

. -~

a

n

application bearing .

th

e .
. . .

n

e.

w

ow.ne.r~s.

n

ame.{p

et .

t

i

n

eh '

t

'

:

rl

ew

infcn;matiOJ:l ~d sigrui~tq~e forwarded to the State WIC Office; TJ:levendcn:stanip

be

tetriev~({::froriithepreviol),sowner

.. ...

.. . . ... .

. " "~ . _.._._ . . . . ...

.. .

and

anew

s

t

a

m .

p .

i
-

s
.

s

u .

e. d

td

t.he.. :.n.e. 'W

vendor. .

An inp..u. t

form Will be "fofWatded to ~~ ..t\DP.. contractor by the Local Agency. tetn1inating th~

previous vendor froiij: WICpartiCipation and the State WIC Offise will update the sy5;tern.

with changesfor the hew vendor.

VII. VENDOR TRAINING

Vendor training will be conducted to inform vendors of the appropriate program policies and procedures pertaining to WIC vendors. (See Page VN-56.)

AIJ;newyeiid,o!'S must be trailled prior to accepting.al1y WICvoucliers. A traiiling will be
reqtiired for .:Yendot~Jcietefirii,lled to. ~.high fisk (hig})VAMP scores/flags; ;:co!IlP~am!
letterS/calls, previou~ warning letters, and/or. sanctions)~:. Refer to. the Vendor Trailiilig
Checklist (Attachment VN"~7}foracc:eptable training tools.

VN-7

GA WIC PROCEDURES MANUAL FY '97

VendorAgreemefitR~Ilewal- arihfuilYendotA.greemefit/Corittacfand trainilig pac~~1~
, be sent to vendors via certified maiL Orice store owner/manager receives training Pitket tpey will. be !espoiisibie.for .~~)*tore:.e):tipl()yees ~dIliay desi@iate:;bmpl~y~,{ip conductin"stote-trairtfug~ ;;:pocllfileiltatipiiof\Vh<)ithe store owner!fi:1anager'Hesi@at.~d1o
~~~~~:i~~~:i~1~~~:~;::b~::;=t~

ttafuing; A notarized VehdotAgreefi)ent!Corittacrmustbe retiltriedtoStat~fWIC:Qffice

b)' the design~t(!4 d~adline~









Included in the vendor training process, for the convenience of the vendor, is a Cashier Training Pamphlet. This pamphlet gives detailed instructions on how cashiers should redeem and process WIC vouchers (Attachment VN-11).

All training must be documented, using the Vendor Training Checklist (Attachment VN-7), Vendor Training Information Form (Attachment VN-8), Vendor Training Sign-In Sheet (Attachment VN-9), Post Vendor Training Evaluation (Attachment VN-13), and Sanction System (Attachment VN-19). 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 Vendor Agreement. The local agency should allow vendors a grace period of ten (1 0) working days to attend the District/Unit make-up training session prior to September 30 of the fiscal year. 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 of this form, along with a copy of the Vendor Input7Registration 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 Training Sign-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-10) must be provided to vendors.

VN-8

GA WIC PROCEDURES MANUAL FY '97
VIII. VENDORMATERIALS
The following materials are available from the State WIC Office for vendor training and store use:
-ShelfMarkers/Stickers- _____ Is A WIC Food -WIC Cashier Training Pamphlet -Window Poster- We Welcome WIC Customers -WIC Approved Food Picture Pamphlet (English and Spanish) -WIC Approved Food Poster -Vendor Agreement -Pharmacy Agreement -Vendor Training Check-List -Vendor Review Form -:Application for Vendor Certification Form -Return Voucher Payment Form (Log) -Vendor Handbook -Pharmacy Handbook -Vendor Application Booklet -Vendor Information Training Form -Vendor Training Sign-In Sheet -Post Vendor Training Evaluation -s~ti<?t!:r~I~"@:rffii -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 Reje(itiOn 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 report should be used as a training tool during vendor training.
VN-9

GA WIC PROCEDURES MANUAL FY '97

IX.

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-14) must be used for monitoring visits. (Attachment VN-15, provides instructions for completing the form.) The following procedures must be used when monitoring vendors:

1. Each visit must be unannounced.

2. Introduce yourselfto the store owner or manager and explain the pwpose of your

visit.

3. Complete the monitoring form, which will include recording vendors' compliance

with minimum inventory requirements and recording of vendors' shelf price

information.

4. Review vendors' on hand vouchers for proper redemption procedures (i.e.

signatures, purchase amount, and voucher use/deposit dates).

5. Discuss findings with owner or manager and provide training where needed.

6. The owner or manager must sign the form in the space provided. If they are

unavailable, obtain the signature ~:dat~f;rorii the person in charge.

7.

Give a copy of the form to the vendor
copy;W.the.~g~~~pr~~Ji!~ti,y~).

(futhe

a[)s~n.,~e
....

();f;t:A.~wner/~aii~ettgiy
.. < . .. ...

8. Send a copy of the form to the State WIC Office.

The State WIC Office will review the form, assign sanction.S for violations when

applicable, and notify the vendor of the sanction.S issued Witl.riji?si}..1)i}f~0) {:ic3:Y'IH~f

~e~ei:P!:f>IJ~~.;~P,4<?f'R#:Yf~\!f.o@:l

..

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

If violations are found during a monitoring visit (excluding vendor s~1::freviews), another visit should be made within sixty (60) days to determine ifth~ Violation(s) have been corrected. If the violation(s) have not been corrected, additional sanctio~ will be assigned.
By March 1 of each FFY, the State WIC Office will submit to each District Office a list of vendors 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 1 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

VN -10

GA WIC PROCEDURES MANUAL FY '97

FFY-to-date. This procedure will provide Districts with information that will assure 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. (See'Page:NN-12,Lbcal':Agency~s

. . . .

. .

.

..

.

.."> ...... <

:



E:esponsil5ilities~)

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 of vendors to be reviewed will be determined by the State WIC Office.

The State WIC office will assemble pertinent information concerning vendor
operations in the District prior to the review, which may include the following:
* Bank reports related to rejected vouchers * VAMP Reports ofproblem 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 ofDistrict Vendor Management Review

With the assistance ofthe WIC ProgramNendor Coordinator, the State Reviewer shall identify high risk vendors, through the evaluation ofVAMP Reports. Once the high risk vendors are identified, the reviewer will conduct unannounced vendor monitoring visits. (Depending upon the number of high risk vendors, Local Agency assistance may be required.)

VN -11

GA WIC PROCEDURES MANUAL FY '97
Local Agency's Responsibilities
Local Agencies should prepare a file for each vendor, inclusive of at least the following information for record retention:
* Copy of original Application * 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 iftriliiiingis providec1WyLc@ilo(Sta.te.A:gehcy)
* Monitoring Forms Within past ~~e y~&s, phi; the current year * O~b:tVendor Activity Monitoring Profile {~):}t~p9rt * 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 Input/Registration forms sent to ADP Contractor and State
WIC Office
* Sanction System * Post Vendor Training Evaluation {i~ttaining.is proyid~d-by Local or Sf,a.i:~
AJ. te.n..c.0'/]..:
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 30 days after approval. Also, the use of the Annual Post Vendor Training Evaluation is optional 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.
X. 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).
VN-12

GA WIC PROCEDURES MANUAL FY '97

~- VENDORSANCTIONS

Any WIC vendor found to be in violation of Program policy and/or regulations will be assessed a s~ction value consistent with the severity of the violation. Each violation of Program policy and/or regulations has a set sanction value and a specific time period during which the sanctions will remain on the vendor's record.

All sanctions earned are retained on the vendor file for a period of one (1) year. Sancti()h$

will "roll-off' one (1) year from the date of receipt. The p~rioq ofciisqualifit~tio~.;i~

deter@ned ;qy:, p-f. ~~v~rity :~a fiafure of the. Violation{ the htti:ribetof vi(;lati<.)hs,

probati()ns, 3il<lpilt9isquaJ.iftcati(j!1S.. AiiY. y~ndor disqualifieq frOiil...WIC Program

p~cip#~()tf'm:iY..J?# csqt.t~Ii~~d.fr<)lll the Food Stamp Progriun. .



The actual disqualification periods are determined using the same formula for every vendor. A description ofthe sanction system and how it works can be found on Page VN57 of the Vendor Handbook (Attachment VN-10) and the Sanction System Form (Attachment VN-19).

All complaints made against a grocery store must be documented using the Incident/Complaint Form (Attachment VN-16). Individuals making complaints may choose not to give their names. Copies of this form should be mailed to the appropriate agencies (i.e., District WIC Office, State WIC Office).
Whericoinplairits arereceivedagairistWIC vendors, a lettershould be ~eht stat41&dt@ ofthe.complaip,fanO.quotihgtegulations that~e potentiallfin.viol8_tioh a!ld.the.@.etipn (ifapplicabl~) that cou}O b~ assess~d.
In the event an immediate resolution is not reached, the Local Agency must update the State WIC Office of all unresolved complaints and Vice versa. Whei\~fc()mplairitis~~~t~'d
to potenti~ fr8.l!ct {~}Cshangilig M<=:V()uchers for:gas;'cash, non food items; etc:}t4e B9~a1 Agericywustfo~JoV{:theseprocedm:es.at a Illiriin1umlbm not limited to:
1. S~il~! a1e~~t y.ofi:fyirig tli vendot:ofthe reported potential Violations, and iriformthein
ofthe sanctioiistharcolJ.l<l be assessedfotsuch violations.
2. Send a cop)iofven(iornotifica~orilettertothe'State WIC Office.
3. Sefid a. copy?fco1llpliaritforriltothe State WICOffice~
VN -13

GA WIC PROCEDURES MANUAL FY '97 4. Serid Requestforlnvestigation to the State WICOffi~e.
Documentation of all complaints must remain on file in accordance with the program record retention policy.
XIII. TERMINATIONS/DISQUALIFICATIONS
Vepdg!~:sc~}guled;fot,!~tt:gination will receive'it se.s9fl5f:Wrltt~4'o/affiin~.fi<)rn th~ ~1~1~
WICQffic~~t?tit the. Y~Iii:lC>t 1ftaY complete. a conu.acr~~dridtifti'!{)~ avoid tetftiinati2i}liy
follo\\l'ing these procedures:
1. TCAh~e~.bvheijnidkonrt:.)YvNi:J~l~.trejc(e''iv'ea..WICPro..gra..n. i,.'.C'o'n'tra'ct.A...d..d.erid. um .:V .ia .c..ertifie.d..:.i. na,i,l
3.
VN -14

GA WIC PROCEDURES MANUAL FY '97
.WI receipt.by t}J.evendpr~:Qle:yendor Will pe terminatedfrom CProgram partidpation.
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, of the date oftermination 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 Input/Registration form to terminate vendors from the ADP Contractor. When completing the Vendor Input/Registration form, do not enter the vendor type. This field is for initial certification only and will be completed by the State WIC Office.
A copy of the termination letter, Vendor Input/Registration form, and vendor stamp(s) must be sent to the State WIC Office within thirty (30) days of termination. Also, the District Office must submit Input/Vendor Registration forms to the State WIC Office within thirty (30) days of disqualification of vendors.
Every six months, the State WIC Office will distribute to the District Offices a vendor activity report to update the District ofoutstanding Vendor Input/Registration 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 Input/Registration 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.
If a vendor stamp cannot be retrieved because of a store fire, theft, or the manager/owner was unable to be located, submit the Vendor Input/Registration 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 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 right to a fair hearing. When a vendor is disqualified, the local agency will retrieve
VN -15

GA WIC PROCEDURES MANUAL FY '97
the vendor stamps and submit them to the State WIC Office. ' Probation Period for Hardship Cases
If disqualifying 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 (1 0) 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 fr{)lJ:l til~:<lat-pfn()tificati9Ji;~r:gii#.~&Ip!~7Vi9latimi(s). During a vendor's
probatioliary perlod, the state has all opp6ffih1iey1:6 r~etuitadditional 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 of participant hardship must be conducted by the WIC Vendor Coordinator or designee and determined by the State Agency. Thi$f~VICY~fi.(ftit:f{i;9"6~Mt&f:?m~
=~:~r:t~~;~i:::~~~~~
yif.g()r.Willcrea:~~-hat9-$1liP.~(:):JYIC p~g~patit$5wtntethepistti~tft.!ili.t,<This form shall be received by the State Agency ten (10) worldfig 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.
XIV. VENDOR FAIR HEARING PROCEDURES
Vendors may appeal decisions of the 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 Offic~_(jfStateA~~t!ye I-J:eaiifl~~ will schedule a hearing date within forty-five
VN -16

GA WIC PROCEDURES MANUAL FY '97

(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.

The proposed adverse action must be postponed from the time an administrative fair
hearing is requested until a decision is reached by the Administrative L.~"'Y I:-g(:l;e. Vendor
hearings may be rescheduled one (1) 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 A--.d.m..i.n.i.st.r. at.i.v..e.-...L~..\.V..'.,..N.:..<.l.~.e:{A L.J...)..}!O. ffic..e...o..f. Stat.e ?.J\driJ.i.n..i.s .t.r.a.t.i\1~ ;\.P-P'er.u...s.;. is an
impartial decision maker with no personal involvement or interest in the outcome of the hearing. The :AMJ?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 of fact and conclusions of law.

The ~Jaild1ll:eState 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 ~J 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).



XV. 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 of WIC 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

VN -17

GA WIC PROCEDURES MANUAL FY '97

following definitions correspond with the alpha-numeric variables listed under the "vendor scores" field of Attachment VN-17):

A B C D E F G H I J K L M N 0 P -
Q -

Small Amt. of Price Variation Large percent of food instruments redeemed at same price High average price C1 - Peer C2 - Flag Redeemed price higher than Vendor Price List Large percent of High-priced FI El- 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 of Manual food instruments redeemed by Vendor Large percent of food instruments with consecutive serial #'s redeemed by vendor High percent of food 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-17) summarizes the vendor's activity.

Once a quarter, the State WIC Office will send the Local Agencies copies of the VAMP Reports for all vendors in their area to be placed in each vendor's file. They may use this information as part of their local monitoring efforts.

XVI. MINIMUM INVENTORY REQUIREMENTS WAIVER

Minimum inventory requirement waivers will be granted to vendors whose store is located in a zip code area whereby the WIC participant population is fewer than six women and/or children and six infants. Therefore, the minimum inventory requirements will be reduced to satisfy the needs of the WIC participant population that reside in the vendor's zip code area. (The minimum inventory requirements reduction will be determined by the State WIC Office.)

VN -18

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1

VENDOR APPLICATION BOOKLET

WIC
Vendor Application
Booklet
Georgia Department of Human R~sources
FFY 1997

VN -19

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Contents
Introduction The Application Process Vendor Application Dead~nes 'WIC Minimum Inventory Requirements 'WIC Approved Foods List Form 3770 (I)-Application for
Vendor Certification Form 3770 (2) Form 3774 (1)- Vendor Review Form
(2) (3) (4) Form 3771 (1)- Vendor Agreement Form 3771 (2) Form 3771 (3) 'WIC Vendor Agreement Between Military Commissaries and Local Agencies

VN-20

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Introduction ___________________________

R tail food stores play a critical part in rhe WIC Program. As the actual distributors of he special WIC foods, the vendors are essential in their role to help improve the nutritional statuS of the members of their communities.
The WIC Program benefits the vendors who are selected to participate-not only because of the direct

contribution of WIC food sales, bur also because the WIC participants who go to an authorized vendor to obtain 'WIC foods normally purchase other products at the same time. In rerum, vendors are expected to exhibit accounrauie behavior-both with the participant as well as with the WIC 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 store owner must complete the application
(see page 5 for a copy of the application) and Vendor Review Form and return these forms to the Local WIC Agency.
Step 2 - Processing the Application After the Local WIC Agency receives the com-
pleted appliC:ation, a pre-approval visit will be made to the store by the Local WIC agency's representative.
The following criteria must be met before a store can be approved for WIC participation.
1. Upon the sale of a \VIC-authorized store and the purchase of a previous \VIC-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.

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 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.
7. The store must be open for business at least eight hours per day, six days per week.
8. \VIC foods must be within current manufacturer's date limit for human consumption.
9. The vendor must be located within a reasonable distance of participants.

2. Store must have the minimum inventory. All retail grocery stores are required to stock a minimum inventory of WIC-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 of non-perishable WIC food items 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 the state average by peer group 1 store prices.

10. The Food and Consumer Services Office of the United States Department of Agriculture reserves the right to approve any uses of the WIC acronym. The "WIC" acronym and logo cannot be utilized by a store or on a vehicle with the exception of documents distributed by the Georgia WIC Program.
Applications are accepted each weekday and should be returned to the Local Agency to be processed along with the Vendor Review Form that is' completed by the vendor. The application process takes fory-five (45) working days for completion. Therefore, vendors who wish to receive approval or denial regarding WIC vendor authorization must

1

VN -21

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

submit a completed \VIC application form forty-five (45) working days prior to store opening or change of ownership. All retail vendors will be subject to the same application process. WIC vouchers must not be accepted by vendor applicant during the application process.
The Local Agency will forward the VendorApplication for Certification with the Vendor Review Form (vendor's self review) to the State WIC Office within five (5) working days.
The State Agency will review the above documents within fifteen (15) working days for the following: a. The application will be reviewed for accuracy and
a background check will be conducted. b. The vendor's prices will be analyzed to ascertain if
prices charged for WIC approved foods meet the state pricing standards. c. The vendor's Department of Agriculture and Food Stamp Program eligibility will be verified.

d. The State WIC Office will fax/mail preliminary approval notices to the Local Agency within this time period.
e. The State WIC Office will fax/mail denial letters to vendors and the Local Agency within this time period., Denied vendors may correct deficiencies
_ within thirty-five (35) working days of denial. If a vendor does not correct the deficiencies within thirty-five (3 5) working days of denial, a new vendor application must be re-submitted to the Local Agency.
Upon receipt of the State WIC Office preliminary approval of a vendor, the Local Agency will conduct an on-site monitoring visit of the store and tentatively schedule vendor training for new store personnel (owners/manager/cashiers/etc.) within fifteen (15) working days. The following processes will take place during the Local Agency review: a. Non-perishable items must be in the vendor's

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

I I Quantity

Size

Number of

Types!B=ds

Milk: (Pasteurized) I

20 J

1 Gal.Jug

I

1 Brand

Note: Quantity may include whole, 2%, 1%, and skim milk in the gallon size container only.

Cheese:

16

1 Lb.Pkg.

2 Types

Eggs: (Grade A Large

16

1 Doz. eggs per carton

1 Brand

Juice:

24

46oz. can

12

12 oz. frozen container

22y~ pes

Cereal:

30

9-20 oz. box

Note: At least two (2) types of cereal must be in 12 oz. size.

4Types

Peas/Beans:

8

1lb. pkg.

2Types

Peanut Butter:

8

18 oz. jar

2Brands

Formula: (With Iron)

186*

13 oz. can

1 Brand

Contract brand of formula only. Vendor must be able to supplv soy, powdered, ready-to-feed, concentrate, LactoFree or a different brand offormula upon request.
Vendor must stock a minimum of 32 cans ofProsobee (soy-based contracted brand) formula, 16 cans of LactoFree (lactose reduced contracted brand) formula and 138 cans ofEnfamil (milk base Contracted brand)
formula. Note: Low iron formula does not meet WIC minimum inventory requirements for formula.

Infant Cereal:

12

8 oz. box

Note: At least one (1) type ofinfant cereal must be rice.

2Types
..

2
VN -22

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

WIC Approved Foods List

Food Item
Milk (Pasteurized)
Cere:1l

Brand or Type
Whole. Skim. 99% Fat Free. 0%. or low Fat (2%) (Le:lsl E."<pellSive Brand Only)
Acidophilus. Enjoy. lactaid. laCI:Iid 100 Nuuish or Dairy Ease Evaporated Powdered UHTMilk
I
Oleerios. Ole:"< <Com. Rice. or v.hc:w. Crispy Critters.
Country Corn Flakes. Kix. Nabisco Quick Cream of Wheat <R<gubr fb\'0<). Produa 19.Jim Dandy Quick Grits (Iron Forufo<dl. Minute 3 Brand Instant Oatmeal (R<gular FbvorJ. Harvest Instant Oatmeal(R<gular~J. Harvest Instant Oauneal (Regubr &-orl. Quaker Instant Grits or Oatmeal <R<gubr ~>-Total-Com Flakes. Kelloggs Special Kor Corn Flakes. Kelloggs Complete Bran Flakes. Quaker Sun Country Quick Oats (Fqubr Fb\'Ofl. Quaker Oats Crunchy Corn Bran. Ralston: Optima 100 Whole Wheat Flakes. Enriched
Bran Flakes. Nutty Nuggets. Instant Oatmeal <Regular ~l. Crispy Rice. Com Flakes. Tasteeoffoasted Oats. Crispy Com Puff
Ralston Stan: Brands Allowed: Kroger. Koon<ry Fresh. IGA. Red & White. Flavoritc or Nature~ Best

I Cont:liner/Pkg Size
One Gal Size ONLY (Exception: 112 Gal or Qts. of Enjoy. I.aaaid.l.actaid 100. Acidophilus. Nuuish and/or Dairy Ease.12-0z cans Evaporated. 3 or 5 Qt. Boxes Powdered. 8-oz. Box UHT Milk
(9) Oz. Sizes and Above ONLY
Can pun:h:lse more than one (l) type/brand of cmal as long as the amoum does not go over the quantity on the front of the voucher

Cannot Buy
Flavored Milk. Buttermilk. or Goat's Milk
Eight (8) Oz. or Less Size Boxes

O.eese

American (lndn,d\Uily \\lopped or lin..-r2pped Sliced or Blockl.
Oleddar <Bio::kl. Colby <Bb:l<l. Monterey jack (Block). Mozzarella (Btockl

Nine (9) Oz. Up to 16-0z.
(One Ill Pound) Size ONLY

Oleese Food. Shredded or Deli
Oleese. and/or 2-8 Oz.Pkgs. for 1 16 Oz. P~ (no 8 Oz. Pkgs Oleese)

juice (100$ USRDA Vaumin C Fonifiedl
.

~e: Lctst "Elqxnslvc Brand Only
Gra ruit: last Exp:nsi'" Brand Only
jGrape: v.<:lch's orJuicyJuice. White Grape: W:lc:IU&n= !Apple: Flavoruc. Lucky laf. SWT. Shur Fine. Kmgcr.Juic)Juicc
Seneca (R<d I.Jbel Only). Thrtfty Maid. White t1ous<
pther: iDoJe: Or.ong</Pinapplc. Dole ~iciB=na
Ptnopplc/P=nl&nara. Plneappi<.Q~.
Mandarin T:zng<nn<. Mouruin Ol<ny. Oldwd Pach
Counuy !Wpbcny. Tropical Fruil. ~ uicyJuice: Cheny. Punch, Ttopic:ai.Sa-...b:ny.~
Ot>nge Punch. Bcny

46-0z Cans. 6 oz.Cans or 120z.Can Frozen ONLY

juice Drtnks. Fresh
Squee:zedjuice. Single Srmg. Sizes, lnfm1 juices, juices 'Mth
Sugar Added

Eggs (Grode A Larp: ONlYJ

Least Expensive Brand Only

One (1) Dozen

Any Other Size'Qnty.

Dried Pez'Beans

Any Brand Wuhout Flavoring Added

One (1) Pound Size ONLY

Any Other Size/Qnty.

Canned Peas'Beans

Any Brand 'Mthour Flavoring Added

15 Oz Cans ONlY

Any Other SizeiQnty.

Peanut Butter

Any Brand WuhoutjellyAdded or Honey Spread 18 Ounce jars ONLY

Any Other Size/Qnty.

lnfm1 Formula

As listed on the Front ofthe \bucher

As Listed on Front of\buc:her

Unlisted on Voucher

l.nfant Cereal (Boxes Only)

Beech Nut. Gerbei; Heinz

Dry Cereal in 8 Oz. Sizes ONLY Any Baby Food in]mor

.

Any Dry Cereal wirh Fruit or Formula Added

Tuna

Water Packed ONlY

6 Ounce Cans ONlY

1iJna Packtd in Oil

Carrots

Fresh. Whole. Canned-Medium Cut

One (1) lb Presealed Plasdc Bagor Bulk, Frozen.

15 Oz. Canned Slia:d

Shreddexi, orBabyCanas

3
VN -23

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

store within fifteen (15) days prior to store opening or change of ownership as specified in the \-VIC application.
b. Thus, the Local Agency must be allowed to conduct an unannounced on-site monitoring visit anytime during this fifteen (15) day period, during standard busirtt:ss hours (8am-5pm).
c. The Local Agency will fax and mail the Vendor Review Form (pre-approval visit outcome) to the
State wrc Office within this time period.
The state 'WIC Office will render approval or denial of the vendor application. a. If a vendor is approved, the 'WIC authorization
stamp will be forwarded to the Local Agency with a copy of the application and the vendor registration form. Therefore, the Local Agency can proceed with vendor training as scheduled and the owner or manager who is legally responsible for the store can sign the WIC Vendor Aoareement!Contract.
b. If a vendor is denied, the State 'WIC Office will fax and inail the notice to the Local Agency within five (5) working days. Likewise, the State 'WIC Office will mail the vendor his/her denial notice via regular mail within the same time period. The Local Agency will cancel the tentatively scheduled vendor training session upon receipt of the denial notification. Vendor applicants may correct deficiencies within thirty-five (35) working days of deniaL If a vendor does not correct the deficiencies within thirty-five (35) working days of denial, a new vendor application must be re-submitted to the Local Agency. New vendor training may take place if training
did occur previously. In addition, the vendor owner/manager will sign the Vendor Agreement/Contract and receive his/her WIC authorization stamp during this time period. A copy of this agreement/contract is included on the following pages.
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/Contract.
Once the store owner/manager ~ceives the training packet, they will be responsible for

training store employees and may designate employees to conduct in-store training. State and District \VIC staff are available to provide subsequent training.
The Local Agency will conduct a new vendor . on-site monitoring review within thirty (30) days upon 'WIC vendor authorization. Therefore, the store must meet the 'WIC minimum inventory requirements on perishable and non-perishable WIC approved food items upon authorization and anytime the store is open for business.
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 part of this information package.
Any applying 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.W., 8th Floor
Atlanta, Georgia 30303 (404) 657-2900 or WICHotline 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 WIC Program.

4

VN -24

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Georgia Department of Hu= Resources DMSION OF PUBUC HEAL1H
FOR WOMEN. INFANTS AND CHILDREN
WICPROGRAM APPLICATION FOR VENDOR CERTIFICATION

Area Code

S.. tore Name
Store Location
Mailing Address (If Different)

Telephone Number

City

GA

(___)
Zip Code County

Store Owner

Store Manager

F.E.L Number

or Owner's Soe. Sec. Number

(Federal Emplcyor /d_entifier)

TYPE OF STORE

HOURS OF BUSINESS

OChain

Sunday

Monday

Q Independent

Tuesday

Wednesday

Q F:anchise

Thursday

Friday

ODrug

Saturday

Square Foota,11e of Store
(Squa'e """'""'o Gtoe=y S-= u4 Gcoocty Sco<oge Spoco~
Average Annual Gross Sales S

Number of Check-out Coun!CtS

Estimalcd Total 9& of Food Sales

_%_

FoodStampAumori~onNumber

(A stol"e must be eligible Cor Food Stamp Program Authorization to be a WIC Vendor.)

Department of Agriculture License Number

(A store must be licensed by the Department ofAgriculture to be a WIC vendor)

Business License Number
Lengm of llme business has operalcd at me present site

Sales Tax Number

Date stOre will open/change of ownership date

Yes No

Q

Q

Do you sell beer, wine, or omer alcoholic beverages1

Q

Q

Has me business ever operalcd under anomer name? If yes. what was me name of me business?

Q

Q

Is this a change of ownership?

Q

Q

Does this store now participate in me Food Stamp Program?

Q

Q

Has this store ever applied for WIC11f yes, state when

Q

Q

Has this store ever received a warning. been suspended. disqualified. or had a penalty assessed against it by

- .....

WIC or Food Stamps? Ifyes. state when and explain

STATE WIC OFFICE USE ONLY

Food Pkg.l#

Vendor Cost

Food Pkg.l#

Vendor Cost

FoodPkg.l#

Vendor Cost

Ace stoce prices compellllve with omer stOres in State?_ _

Max Max Max _ Yes_ No

Applicallon:

Approved Deaied Reason Denied

Date
-Date~

Vendoc Number Assigned Processed by

F - 3770 (Re-r. 7961

Price Approved _ _ _ Denied _ _ _ Price Approved _ _ _ Denied _ _ _ Price Approved _ _ _ Denied---
Pagel or%

5

VN -25

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

'
I
Store Name

Name of bank when:: WIC vouchers will be deposited

Dairy products are received from

Other WIC products are received from
a Do you own or manage any other grocery ston::(s) I drug ston::(s)? Yes

a No

If yes. list name and addresses of ston::(s)

To the best of my knowledge. all of the above answers are correct. I understand that. should my store be accepted as a WIC vendor. I will abide by WIC Program regulations and policies including, but not limited to the following:
l. AUend Vendor Education: 2. Train employees regarding WIC procedures: 3. Periodical monitoring and; 4. All items in the Vendor AgreemenL

I UNDERSTAND TIIAT THIS IS ONLY A REQUEST FOR APPROVAL AS A WIC VENDOR AND DOES NOT CONSTITUTE APPROVAL TO PARTICIPATE IN TilE WIC PROGRAM. TIIEREFORE, I WILL NOT ACCEPT ANY WIC VOUCHERS UNTIL SUCH NOTICE OF APPROVAL HAS BEEN MADE, I HAVE ATTENDED VENDOR TRAINING, AND I HAVE B~ ISSUED A WIC VENDOR STAMP.

Signature

Date

Title

lb:s is an f.quoi Oppom:nity l'ro6r.un. f=ocs who belie..: lhcy luvc becD cfiscrimilwed apiosl bc<::luse of raa:. colot.aalional origin. sa.""'- oc hondicop should
wrire illlmediardy to Sec:rctoty of Agricall=. WashingtOn. D.C. 202S0.

YES NO
a a
Comments:

FOR LOCAL USE ONLY Is the state required minimum inventory ofWIC approved foods in the store during the Pre-Approval visit?

a a
Comments:

Have you provided the vendor with the Georgia WIC Application Packet?

I certify 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:

DISTRICI' UNIT F-3770(Re..1-96)

LOCALAGENCYWIC COORDINATOR OR DESIGNEE
6
VN -26

DATE

PlceZoU

'

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Gaorgia Clepat1ment of Human Resources
Division of Public Health WIC Program
VENDOR REVIEW FORM

Vendor Number--------- Page 1 of 4 District _________ U n i t - - - - - - - Date of VISit

VenaorName

Store Owner

Street Address

Cry

Review Type

Q Vendor Self Review (attach to Vendor Application)

Q Pre-Approval Visit (Non-perishable Food Review) Q Yearly VIS~

a New Vendor (not applicable as yearly visit)

a Fotlow..lJp Vs

Store Manager County

Zip Code

Q Minimum Inventory Waiver Granted Q Regular Minimum Inventory Required

Note: Physical Inventory must be viewed by WIC representali\le at the time ol visit. Proof ol order ol fOOd items shall not be accepted.

A.

Minimum Inventory Aequiremerus

Juice: t. Are there at least 24 cans of Mi oz. size juice in stodc? If no, how many cans? _ _ 2. Are !hare at least 12 cans of 12 oz. size frozen juice in stodc? If no, how many cans?_ _ 3. Are !hare 2 types each of frozen and canned juic:e? If no, how many? Cans__ Frozen _ _ 4. Was price manced on juice or posted on the shelf/dairy case?._ _ 5. Was juice within date litrit? If no. how many were not? Cans__ Frozen _ _

Yes

No

Q

a

Q

Q

Q

a

Q

Q

Q

a

Apple
Grape: White Grape:
O~ange:
Other: Dole
~Juice

Brand Name Flav-o-rite Kroger Juicy Juice Lucky leaf Seneea (Red Label) ShurFine Staff Thrifty Maid White House Juicy Juic:6 Welch's 100% Welch's Seneea Least expensive only least expensive only Pine-Orange-aanana Pineapple-Orange Pineappte-Passion-Sanan:t Pineapple-<lrange-Guava Mandarin Tangerine Mounlaln Cherry OtdlardPeach Country Raspberry TfOI)ic;al Fruit Pineappte-Giapetru;t Cherry
Tropic:~~~
Punch
Strawbenv
APPI~rape

NIS

P~:Mioz.

NIS Prices: 12 oz. Frozen

$

$

$

s

$

s

$

$

s

$

$

s

$

$

s

$

$

s

$

$

$

$

$

$

s

$

$

$

$

$

$

$

$

s

$

$

$

$

$

$

$

$

$

$

$

$

$

$

s

s

$

$

$

$

$

$

s

s

$

s

Oranoe Punch

$

$

~onJulce: _______S_en_v __________________________$____________$ _______- ;

Fo<m :fn4 (Rev. 796)

Rcuting: W1it8. Slats Wlc O!llce Yellow lOCal Agercy Pink Vendor
7

VN -27

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

'

Vendor Number
Cereals: (At least two types in 12 oz. sW.S)
1. Ate lhere at feast 30 boxes of 9 oz. to 20 oz. size o1 cereal in stOCk? If no. how many? _ _ 2. Are !hera at least 4 types of WIC cereal in stOCk? II no. how many? _ _ 3. Ate !hera at taas/2 types of 12 oz. size boxes of cereal in stOCk? 11 no. how many? _ _ 4. Was price marlced on cereal or on shelf? 5. Was cereal witl'lin date ~mit? II no. how many were nor? _ _

NtS

Oz. Size

Clleerios

ComChex

Rica Chex

WheatChex

Country Com Flakes

Crispy CrittaiS

Kix

Kellogg's Com Flakes

Special K

Product 19

Total. Com Aakas

Harvest Instant Oatmeal (Regular)

.run Dandy Quick Grits (Iron Fortified)

Minute 3 Brand II'IStant Oatmeal Plus Oat Bran1Regutar)

Nabisco Quick Cream .ol Wheat (Regular)

Quaker Instant Grits (OriQinal)

Quaker Instant Oatmeal (Reoutar)

Kellogg's Complete Bran Blakes

Quaker Sun Country Quick Oats (Regular Flawr)

Quaker Oats Crunchy Com Bran

Rafston: Optima tOO Whale Wheal Flakes

Enriched Bran Flakes

Nuttv NUats

1ns1ant OatmaaJ {Regular Flai/Qr)

Cdst>v Rice

Com Flakes

TasteeofToasted Oats

Crispy Com Puff

Rafston Store Brands Allowed; ~r. K~ Fl1!sh. IGA. Red & WMe. FlaYotite or Natu111's Best

Comments on Cereal:

Peas/Beans 1. Ate !hare at least 8 bags of 16 oz. size peas/beans In strx:k? If no, how many?_ _
2. Are !hare at least two types of peas/beans? If no, how many'L_ 3. Was price matlced on peas/beans, or on sheff?

Brand

Type

NIL-

Comments en Pa8SI9eans

Page 2 ol4

Yes

No

a a

a a

a a

a a

a a

Highest Prices
s s s s s s
$
$
$
s s
$
$
s
$
$
$
$
$
$
$
$
$
s s
$
$
$

Yes

No

a a

a a

a a

Highest Prices

$

$

Peanut Butter: (No peanut buttetljelly combinations or Honey Spreads) 1. Ate !hare at least 8 Jars of 18 oz. peanut buller In strx:k? If no. how rnany:Z_
12. Ate !hare at least two bnlncls ol peanut bullar? If no. how many'L.._ 3. was price matked on peanut lxdlar, or on Shaff?

s Highest Ptlce

ant!

eornr-= en Peanut Butler.

NIS _ _ Brand of Peanut Butler

Form :r774 (Rev. 7-96)

Routing: Wl1lta State Wic Olfic:e Yellow L.ccal Agert::y Pink Vendor

Yes

No

a a

a a

a a

8

VN -28

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Vendor Number

Infant Cereal: (At Least one type of cereal must be rice) 1. Are ll1ere at least 12 boxes of 8 oz. size of infant cereal in S:CCX? If no, how many boxes?_ _ 2. Is rice c:erea1 in stock? 3. Is l!lere one olller type. oll1er than rice, in stcc:k? 4. Was price marked on cereal or on shelf? S. Was cereal within current date limit? If no, how many were not?_ _

Brand and Price of Infant Cereals: Beed'lnut Gerber Heinz

Rice (Highest Price) $ _ _ _ __
s _ _ _ __
s

Other (Highest Price)

NIS

$ _ _ _ __

$ _ _ _ __

$

Page3 of4

Yes

No

a a

a a

a a

a a

a a

No
a a a a a a a a

Mille (Minimum at 20 gals. whole milk, 2%, 1% & eklm milk of the !eat expensive brand)

1. Are lhere at least 20 gals. of milk In stcc:k? If no, how many?__
2. was price marked on milk or posted on ll1e dairy CSS<J?

HIS--

3. Was milk within c:urrent date limit? If no. how many were not?_ _

Lowest Price:

Brand of Milk

Cotrrnents on Mille

Cheese 1. Are there at least 16 one pound packages of cheese in stcc:k? If no, how many?_ _ 2. Are lhere at least two types of cheese in stcc:k? If no, how many? _ _

3. Was plica marked on cheese or posted on the shelf/dairy case?
4. was cheese witl1ln date limit? If no. how many were not?_ _

Highest Prices of Cheese: American $ _ _ _ HIS-- Colby

HIS _ _ Cheddar

NIS

Monterey Jack

NIS_ _ Mozzarella $ - - HIS--

CommeniS on Cheese:

Eggs: (l.eat Expensive Brand)
1. Are lhere at least 16 doz. Gtade A Large eggs In stcc:k? If no. how many?--
2. Was plica marked on eggs posted on the dairy case? 3. Were eggs witl1ln dalllllmit? If no. how many were _ nat:~ _

Lewes! Price: S

and (Grade A Large)

CommeniS on Eggs:

HIS_ _

Brand of eggs

Form :g'l4 (Rev. 796)

RoCiting: While - Stale Wlc Ollica Yellow Local Agency Pink Vendor

Yea

No

0

a

a a

a a

Yea

No

a a

a a

a a

a a

Yea

No

0

a

0

a

0

a

9

VN -29

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Vendor Numbet:..------Page -4 ol-4

B. Panic:ipanWendor Observation (Not applicable for pre-apptOVal)
1. Were any WIC VOUChers on hand in lhe store? If Yes. were an voucher amounts filled in? - If the voucher amount is not fiUed in. list the voucher number(s) in the comments section
2. Observed WIC patticipant making a pun:hasa? If Yes. were appropriate procedures followed? _ _
Explain ina;)pfcpria1e procedures:

Yes No NA
c c Q
c c Q

Comments
C. G-'lll Questions/Observations
1. Does the SIOnl need to be referred to the Geotgia Oepamrent of Agriculture for inspe<;tion? 2. Is store open for bc.rsiness at least 8 hours a day, 6 days a week? 3. Has discrimina!ion been reponed or observed?
4. Is there a need tor additional training at this time? 5. Ate all price calumns for foods not in store martced NJ.S. (Not in Store). This answer must be yes.

Yes

No

c c

c c

-

c c

c

0

c c

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/agreement or within the contract period. The results of this monitoring visit have been discussed with me and I understand the violations (if applicable) that were found and the food prices listed above are correct.

Data: _ _ _ _ _ _ _ _ __

PrfntNameotVendorR~
I have discussed all findings, any violations and training needs (if applicable) with the appropriate vendor representative.
Data:----------
Prfnt NameotWICR~
~~----------~--------------Vendor Representative Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

WIC Representative C o m m e n t s = - - - - - - - - - - - - - - - - - - - - - - - -

Form 3774 (Rev. 7-96)

Routing: White State W1c Ofllce Yellow Local Agency Pink Vendor
10 VN -30

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

c...ar,..~ol"*--~
- = - ~oiPublk......,_
(SII'EOAI.. SUPPt,EIIIEN'D.L F0oo ~ F<*WOYEK. ~ & Ota.DRf.MJ
VENDOR AGREEMENT

Page 1 ol3

this llerdor/Pn:Mder Al;lreeme<lt is made by and be!ween the Gea9'a Oeparlmenl ol tUnan Resoutces. !liYision ot PIJblic Health. Health Ois:ric:t

- - - . u n a - - - .(hereinafter nolen-ed to as the Lccaf AQency) a n d - - - - - - - - - - - - - - - - - - - (hereU>alter referred to as the 1/endcr) to l>'ovide a mechanism for the distribution of SQeOal ~ foods to eligible W1C participants in the

caonudrw.tiyliteesrm) ininclauldeeodnin_thi_ s H_ ealth_Oi_ stric_ :t ~_ di_on_. _ This_ag_reement will t>eccme elfedille e n - - - - - - - - - - - - - - - -

The ~ represents the 1/endcr as the sole pcoprielor or the store The undersigned represents the Local Agency and has the authority to

fmSaignnaag'.eurretoMUceSnTtrbaedotfoorwannedr

en behalf ot the or store manager.)

Vendor

idef_;:"~

-

centrad for and en behalf ol said agency.

~CI~Orwtwor~

"'"

(Pnntl NoJrN cl sa. o..n. Cll' MaN;It

,...._OI'tllwl::lot~l

~ ~ ShrftPD. b

SINoeol'l.ocahOnoiSD'eSn'l'l~

c;ey

---s....

zoc:oo.

--o.n.r ,. ,.,...,. 01 Slcn

dlfteNnl frgon ~

Ccy

so...

zoe-

$1;1Wureol&..oc:MIIq/!Jtcy~.cf~

fP'rfti ..... Oit...clell~~... ~

. . . . Oit..cc.l~

~ Aar:ftU .. Slr..c P.O. eo.

Ccy

- -.....

zoc:oo.

__........ bbmatlld...cl fo::ld s.. -
~e...,_~,.,._.

~Nn.t~~Gaus.la

.. ---- Oic:...ft~

-

Notary 1'1.1b6c Signature and Seal

Oate

Nctary Pl:blic"s Commission Expires

PURPOSE:

this Agreement is for the I'Ufl>OSe o1 providing a mechanism for the dislriblulion ol certain listed foods to eiQble participard:s and the ~ ol negoCiable food instruments for the pun:l1ase ol said food items. lhe llendcr is retained solely for the purpose set lortl1
herein and shall not be considered as an ~ or agent ol the [)e!)artment.

lHE VENDOR HANDBOOK IS AN ADDENDUM TO lHIS AGREEMENT.

--

I~~UW._.-.,

--

Form 3771 (Rev. 7-96) Routing: M'llte State lt1C OffiCe, Y - I.Dt2i Agency, Plnl< ~
11

VN -31

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

WIC VENDOR NUM8ER

Page 2 of 3

THE RETAIL VENDOR HERESY AGREES AND COVENANTS AS FOLLOWS:

A. To stock an adeQuate suPPlY ot autt'onl:ed types and t><at>lS ot WIC Program fOOds. on all catego<oes. as delermmed by the Geo<g.a WIC

Program.

B. That all prices Will be clearly ma~ '""'e' on the food item .,.. prominently dlsQtayed. C. To post the acceptable WIC AQQ<O\.Ed FOOdS l.lsl on a cOilSQCUOUS !)laCe by atf cash reg.ste..s

0. To accept WIC IIOUChers fO< payment of the gur<:nase ot only eltgotlle WIC foods tsee Ao!><OYed Foods LISII. fn addrtoon. the vendOr must

accept all valid WIC IIOUCnefs

E. To accept no WIC IIOUCioefs as payment on past "'present eredrt acccunttsl.

F. To accept no WIC IIOUChers from partocoants presented afte< thirty tJOI days '""" the ossuance date "' prOO< to ISsue date shown on the
..oucher.

G. To accept only vouchefs whoch contain a GeOtgia WIC Program SEAL.

H. To refuse acceptance of any food instrument on whiCh any afte..auons have been made.

snen - I;i~;t~u~e:;:;;s1~ or belOw the normal store

price. but not to exceed the maximum amount Usted on the voucner cexduding

J. To permit WIC Program panicipants to purchase eligible food items wi1hOut making other purcnases and to accord sUCh panicipants the same

counesy given to other stO<e customers.

K. To keep all infO<"mation confidential on WIC partoooants. .

L To drect QueStoons conce<nmg payment. ptt)QI'am ooera1oons. etc.. to the Local l>qeney: partiCipants will not be contacted concernng these
01" othe< Dn>blem areas. (Food vendOrs Shall not seek restluloon from partic:.pants lor IIOUChers not paid by the State.) M. To ensure that no exchange of money between the store and part1CJP3Mt takes Dlaee during a WlC 'oiOUChet tranSaction.
N. To allow no rainehecks "' exchanges of any 'oiOUChet for cash. credit CO<.OOOs. stamos. l)(efN.JmS .,.. ncntisted foods: ~. a Vendor is
c:asn. not preclt.ded from giving "' accepting coupons. stamos. .,.. """""'ms willl purc~~ases as iii)UtChased willl

0. To obtain at the time of PUrchase an original custome< SJgnalure on lhe WIC 'oiOUChet and request lhe oartic:iP3nt to show a WIC idenlilication
ard befO<e the purchase of WIC foods can be cC)n'C)Ieted. H the custO<ne< is unable to show a WIC iderrtilicatoon card beanng the same

s.gnature as ~ on the 'oiOUCher. the Vendor should <'Ol acceot the WIC 'oiOUChet as oayment tor the foodCsl. P. To insert. in ~nk. the actual cost of the WIC foods on the WIC 'oiOUChet face at the tome of purchase in the ,eseroce of the custO<"ner.

0. To s<arnt> all >OUChers with the authOI"JZed >endOr stamo (provided by the Llx;al AgencyJ belore deoosrting in the bank and to deoOsit all WIC vouchefs in a timely manner. prefe<ably Within fdteen ( 151 days of r~toon but not mO<e than sixty 160l days from the date of

issuance shown on the 'oiOUChet face.



R t. The owner manage< ..r.o is 1eQa11v ~tO< tile S10re must Sign the vender Agreemenc and stWt attend an manc!a!CltY sclled<Jied CRequ;redl training

5eSSIOnSior W!C Vecldots. ofwNc:ll tm Venc1or"'"' ce rte:JOf;ed by the Local Agerq. T h e - manager wno ~ WIC -lralfling material -..a cet

tified mail a:tends any training se=on<sl .,;a p<Oiide the lllfonnation receMd as training ma:erial fa all trJetr employees wno ate inwlw:<l in WIC pccgr..,

partiCipation, including tile CheckDut Clerks.

_._must 2. A"""""'_...,.,.. managerwno signs an IIU!hentic W!C vendor ~in 11\e absence cl &loc:al state agencywtC

lla-<e

no<"""""' hisot>et \lerldo< ~signed in 111e p<esenc:e cia Nccary Public whOSe C<lnmssion does

prier to the dale mat the Agreement/Conlract

is signed.

macan:nag-er--stcre- 3. Astatewide umorm Pcsr-Test shaH be given to eacll-

d<A'ing -

frain;no. to evalUate ~ objecfNes and guide-

lines set by tne State wtc Agerq - e acnieved. Tlletefore.

manager/OWner whO scores t>e10w the clesired pass;ng gtade cl seventy (701 snau

~for additional tranng. in defiCient areas. with tne Local WIC Agerq. _ .

. T o - to aU emp~oyes- in the Vender's W1C ~ par1iOpolion al conmunic:ations receNedl<om tile l.Dcal~ l)etlinent to tl\e ~

ees ~in the W!C Ptogr;n. To instruct easllie<s. and a1 01t1e< ~ .....,_ in the vendor's WtC Prognsm parlicipation o the eligible 1ooc:l and.

the coroect precessing cl W!C IICIJChers.

5. T l > e - .,;a be ac:councabte for actions of employees ., the -

cl ~ CJ( proy;sion of supplemental fcods.

an S. To abide by rules and regutalions of Federal. State and Local Agencies and p!CCedufes as outlined in the Vendor's Handbook.

T. 1. That the State />J;lencY may deny payments to lhe Food Vendor lor improper fOOd 'oiOUChets "' may demand refunds fO<" payments

a1<eac1y made on improper food 'oiOUChets.

2. To reimbu<se the State Agency within 1l1ir1y (JOI days of tiCiifJCalion for amounts paid by lhe Stale Agenc:y on WIC Program food

..oucherS P<QCessed by the Vendor which are above lhe normal sheH price of foods.
U. To allow .-esentatM!s ot the L.oc:af. State. or Federal />J;lencY to monitor the Vendor's store in an unannounced manroer at any lime lhe

store is open for business. All A!CIO<'ds pef1inenlto this ~ wil be made available for review by the represenla!Ne of the l!lfill!.:'/.
v. That >endOr $lan1)S are lhe property ot the Slate ot Georgia and 11\at said $lan1)S will be returned to the WlC Progtam immedialely """"
tennination/SI.ISI)enSion/d~ocalionl~ wiii'Cawallnlm pn:>gram participation.
W. 1. That the .enctor or the lll!ndor's ~s) wil tiCI reimburse WlC participa(lts or el!Change WlC food Hems, especially infant formula,

when WIC 1IC<.Chers wee used for the purchase unless:
a Notifoed in writing by a heallh department ~We.
b. The .enctor is e>:d1anging a WlC ~ ilem(s) -to~ selfing out-<>1-date WIC foods.

2. That any out-<>1-<late foods wil be n!riiCllo"ed """' SlOe!< and replaced with foods 11\at have e>Cili<ation dates which do not e>ceeed the penxs ot normal expec:ted usage.
X. That any Vendor disquatifoed lnlm anolher FNS Program shall be ~ from part;c:ipation in the WlC Plogram for the same penx! of
lime, uo to three (3) years. Y. A Vendor who c:ammils flaud or alluse ot the pggram is liable to proseaJiion under applic:able federal. state or local laws. Those who
haYe willfully misapplied. SfDien. or fraudulenlly obtained WIC 11n:1s shall be subject to a fine ot not more than S 1D.OOO. or imprisonment

for not more than liYe (5) ~ cr bOih.
AA. To notify the Local Agenc:y ot changes in management or when the Vendor ceases operation or owner.;hip changes. This Agreement is ...a

and >cid l owner.ship d1anges.

N3.. Stale of Georgia or Local Sales T"""" wil not be callec:led on bod items pun::l1ased with WIC .cuc11ers. N:.. To dec:lare that neither the IO!ndor/owner, the lll!ndor's rnanaget(s), cr the ......:~at's clher ~s) is related by blood or marriage to
tJnf WIC ~ unless ofhetwise 1-..!ed in writing, uoan 4!IOI!OIIion of the c:onnct/agreement or wiltlin the c:cnlrac:l period. (space

proAded on DOQe three of this contract ~ for cfiSdOsLI'e of Nlaliloesl NJ. To visibly display the vendor's store name. as listed on lhe front page ol this conlract/agreement, on the CUISide of the store buildi11!l/facifity.
1 To abide by the U.S. Patent and T - t.aw.s. wllicll pohibits unauChorized use of the WIC a:ranym an:l bgo (refer to Registr.ltion

, . . _ 1,630,46S,.proAdedin42U.S.C. 1876, IS.U.SC. 1051 et.aeq.an:I7CFRPatt 246).

Form 3771 (Rev. 7-96} Routing: Whit4 Slltte W7C Office, Y - 1.oca1 Agency, Pink VMdor

12

VN -32

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
WIC VENDOR NUMBER
Name and Trtle of relatille that represents the Georgia W1C Prog<am or ~ by the Georg;a W1C Program:

Page 3 of 3

Office address of relatille that represents the Georgia W1C Program or eft'C)Ioyed by the Georgia WIC Program:
Pnone 1\Unber (olfic:el: ,.__ __!:..__ _ _...;;..._ _ _ _ _ _ _ __
(Please att.ach additioMI pageisl il necessary)
IL lliE LOCAL AGENCY HEREBY AGREES AND COVENANTS AS FOLLOWS:
A. To instruct the Vendor UPOn entry into the D<1>Qt3tn of the appropriate onxedures to process WIC Voucllets. B. To p!OVide the Vendc< with the current list ol fOOds 3llP<"O"'d IO< diSbursement to WIC Program participants and to issue UPdat"s to this
Food List as lhey ClCaJ<.
C. To P<Ooide educational material about the WIC Program to the Vendor.
D. To ins1n.cl WIC participants and 1X0Xies in IX"QP<!f" use o1 WIC vcuc:ners. E. To ensure that an authorized par1icipant or proxy signature is affixed to any manuai>OUCher prior to releasing the ..a.cner IO< redemPI<>n.
F. To notify the Vendor with a copy o1 any changes in 1/CUCilers or use ol 1/CUCilers and any changes in the FeOeral and State Regulations that may affect the Vendor. and to ~ the Vendor witt. a copy ol any WIC regularon(sJ or policy issuanee(sl alfectin; the VeMo<"s participation in the W1C Program.
G. To assislthe Vendor with any problem relating to the W1C Program. H. To provide the Vendor with a uniquely numbe<e<l sta~t>~~.
IlL BOTH PARnES AGREE AND COVENANT AS FOLLOWS:
A. That no conllid of inle<est exists~ the Vendor and the Local~ (See Sect<>o I. AC.I. B. Not to discriminate for reasons o1 age. race, color, sex. national origin or handicap. C. The Vendor has the ng11t to agpea1 any decision made by the Local ~ affectil>g the Vendors ability to pamcipale in the WIC Program
under the terms of this Agreement. D. The pefiod of this Agreement is set lor1h on the signature page. New. agreements win be executed each year. E. This Agreement shall bec:orne nul and wid in its entirety UPOn any changes of owner.;hip of Relaile<. F. This Agreement may be canc::eled by either party with thirty (:lOI days written notice. G. In the ewnt of tetminaron of funds by the funding agercy 1o the State Agerct for the W1C Program, this Agreement tenninates immediately.
H. That neither the Local ~ ncr the Vendor 1>ao1e an obligation to renew the Vendor Agreement. L This agreement/c:ontract does not c:onstiiUie a lioense cr popeny inten!SI. The relationship between the Local /lqency and the Vendor
ends with the l!lCilir.ltion dale of this agreement/c:onlra::l.
IV. SAHcnONS AND APPfAL PROCEDURES:
A. SANCTlONS Vendors shall be disquaified from W1C PRlgram participalion for a period of up to t1vee (3) years if viofalions CICO.II' during a ~oance IU'Chase. monitcring visit by a W1C ~IM>. cr Food Stamp Program participation. Prcc:edures for ~ the sanc6ons ""' cutfined in the Relail Vendor Handbook. Nry -.:lor disqualified from W1C patticipa!icn may be ~ from Food Stamp Program pat1icipation. Refer to 7 CFR 278.
B. APPEAL PROCEDURE Vendors are enlitied to a lair hearing upon disQuaJilicalio from the WIC Prcgram. kry -.:lor teQUeSiing a lair hearing must ccntac:t the Local~ by telephone, and contac1 the Stile W1C Office in writing within fifteen (IS) days after the action wtoic:h is being taken.
V. TERMINAT10H POUCIES:
A. A Vendor shall be t.erminaled from W1C Prog<am pa tiQpcdioco if the sllore is ~licensed by the Georgia Oepar1ment of ~ B. A Vendor 8hal be 1ermina1ec1 from W1C Plagram parti:ipation il the siDle is not eligible lot Food ~ l'lt>gr-.n participation/authorization
or a Veador is witl'drawn fnxn FcocS ~ Pragram paticipatiorL
Form 3771 (Rev. 7-96) Routing: White St.ate wrc omc., Yellow Ll>c&l Agency, Pink v.rncto<
13
VN -33

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

WIC Vendor Agreement Between .Military Conunissaries and Local Agencies for
The Special Supplemental Food Prognm For Women, Infants, and Children (WIC)

e purpose of this \VIC vendor agreement s to outline the basic responsibilities of \VIC local agencies and military commissaries which have been authorized to be ViliC food vendors.
1. In order to be an authorized \VIC 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 supple~ental 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.

vouchers), acceptance of vVIC vendor training within funding/personnel consr:.caim:s, and other local agency guidelines agreed to by the appropriate commissary headquarters except those excluded in item five (5) below. The commissary shall not discrimin.ate on the basis of race, color, national origin, sex, age, or handicap.
5. In view 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) or 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.

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

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 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) Phone Number Signature ofAuthorized Military Personnel Date Signed

Disttict!Unit

Vendor#

Signature of Local Agency Representative

Date Signed

14
VN -34

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

iri
DHR CEORCIA DEPARTMENT OF HUMAN RESOURCES
State 'WIC Program Office Two Peachtree Street, N.W., 8th Floor
Atlanta, Georgia 30303 1-800-228-9173
Standards for participation in the WIC Program are the same for everyone regardless ofrace, color, national origin, age, sex and handicap.
Fonn No. 3746 (Revised 6/96)
VN -35

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-2

APPLICATION FOR VENDOR CERTIFICATION

Georgia Department of Human Resources DIVISION OF PUBUC HEALTII
FOR WOMEN, INFANTS AND CHILDREN
WICPROGRAM
APPLICATION FOR VENDOR CERTIFICATION

Store Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Telephone Number Store Location _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ GA

Area Code
(____) --------
Zip Code _ _ _ _ _ _ _ _ _ __

Mailing Address (IfDifferent) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _County - - - - - - - - -

Store Owner:..__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Store M a n a g e r - - - - - - - - - - - - - - - - - F.E.I. Number_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ or Owner's Soc. Sec. Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(Federal Employer Identifier)

TYPE OF STORE 0 Chain 0 Independent

HOURS OF BUSINESS

Sunday ---------Monday _ _ _ _ _ _ _ __

Tuesday

Wednesday _ _ _ _ _ _ __

0 Franchise

Thursday

Friday---------

0 Drug

Saturday---------

S<Sq<uia=reFoFotoagoetoafaGeroco:efrySSttOofe orned G..ro.c:.er,y.S.to,0:1:ge-S-p->c:e:).----::---:---------- Number of Check-out Counters - - - - - - - - - - - - -

Average Annual Gross Sales$

Estimated Total %of Food S a l e s - - - - - - - - - - " " ' - - - - -

Food Stamp Authorization N u m b e r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (A store must be eligible for Food Stamp Program Authorization to be a WIC Vendor.)

Department of Agriculture License N u m b e r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (A store must be licensed by the Department ofAgriculture to be a WIG vendor) Business License Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sales Tax N u m b e r - - - - - - - - - - - - - - - - -

Length of time business has operated at the present s i t e - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Date store will open/change of ownership d a t e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Yes No

0

0

Do you sell beer, wine, or other alcoholic beverages?

0

0

Has the business ever operated under another name? If yes, what was the name of the business?

0

0

Is this a change of ownership?

0

0

Does this store now participate in the Food Stamp Program?

0

0

Has this store ever applied for WIC? If yes. state w h e n - - - - - - - - - - - - - - - - - - - - - - -

0

0

Has this store ever received a warning, been suspended, disqualified, or had a penalty assessed against it by

WIC or Food Stamps? If yes, state when and explain

STAlE WIC OFFICE USE ONLY

Food Pkg. #-------Vendor Cost _ _ _ _ _ _ _ Max - - - - - - - P r i c e Approved ____ Denied---

Food Pkg. #

Vendor Cost

Max

Price Approved

Denied---

Food Pkg. #

Vendor Cost

Are store prices competitive with other stores in State?_ _

Max _Yes__ No

Price Approved

Denied - - -

Application: Approved _ _ _ _ _ Date _ _ _ _ Vendor Number Assigned_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Denied _ _ _ _ _ _ Date _ _ _ _ Processed b y - - - - - - - - - - - - - - - - - - - - - - - - - -

ReasonDerued-------------------------------------~----

Form 3770 (Rev. 7-%)

Page 1 or2

VN -36

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-2 cont'd

APPLICATION FOR VENDOR CERTIFICATION
S~reN~e ______________________________________________~------------------------------------N~e of bank where WIC vouchers will be deposited - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Dairy products are received from-------------------------------------------------------------Other WIC products are received from ____________________________________________________
Do you own or manage any other grocery store(s) I drug store(s)? 0 Yes 0 No
If yes, list n~e and addresses of store(s) ------------------------------------------------------

To the best of my knowledge. all of the above answers arc correct. I understand that, should my store be accepted as a WIC vendor. I will abide by WIC Program regulations and policies including, but not limited to the following:
I. Attend 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 NOT ACCEPT ANY WIC VOUCHERS UNTIL SUCH NOTICE OF APPROVAL HAS BEEN MADE, I HAVE ATIENDED VENDOR TRAINING, AND I HAVE BEEN ISSUED A WIC VENDOR STAMP.
Signature _______________________________________ Date _________________ Title _________________________________________________________________________

This is an Equal Opportunity Progr.1m. Persons who bcli~ve they hove been discrimin:1ted og:~inst becouse of r.lCC, color. notion:tl origin, sex. oge, or handicop should write immediately to Secretory of Agriculture. Wo.<hington, D.C. 20250.

YES NO

FOR LOCAL USE ONLY

0

0

Is the state required minimum inventory of WIC approved foods in the store during the Pre-Approval visit?

Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0

0

Have you provided the vendor with the Georgia WIC Application Packet?

Comments=---------------------------------------------------------------------

I certify 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 w h y : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

DISTRICT UNIT

LOCAL AGENCY WIC COORDINATOR OR DESIGNEE

Form 3770 (Rev. 7-96)

VN -37

DATE Pagel oC2

STATUS 1 ADD 2 UPDATE
3. TERMINATE

TERMINATION CODE 1 VOLUNTARY WITHDRAWAL 2 SALE OF BUSINESS 3 TERMINATION
4 DISQUALIFICATION
(STATE WIC OFFICE USE ONLY)

MAIL TO:

VIKING COMPUTING, INC.

GA WIC UNIT

.

1000 N. MADISON, S3

GREENWOOD, IN 46142

GEORGIA DEPARTMENT OF I-lUMAN RESOURCES WICPROGAAM
VENDOR REGISTRATION

PLEASE PRINT
DATE ORIGINAL WAS PREPARED--'--'--

STATUS VENDOR NID

STORE NAME

L__j I I I I I

VENDOR TYPE (SWO USE ONLY)
u

STREET ADDRESS

DIST/UNIT COUNTY

TELEPHONE

APPROVAL DATE

III II I I II I II I I I I I III II II I

(AREA CODE)

VENDOR REPRESENTATIVE NAME CITY

DATE PREPARED _ / _ /_ _

<

.Mz

STATE

ZIP CODE

l::;j

'0

~111111-11111
uSTAMPS ISSUED

::0
i~~~
~

~

STATUS VENDOR NID

STORE NAME

UIIIII

w

00

VENDOR TYPE STREET ADDRESS

u(SWO USE ONLY)

VENDOR REPRESENTATIVE NAME CITY

DATE PREPARED--'-'-- ,C"}

r1/-1C

1-3

STATE

ZIP CODE

I~

l...---------'~LI I I I 1-1 I I I I 'z0

DIST/UNIT COUNTY

TELEPHONE

APPROVAL DATE

TERM DATE

TERM CODE

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 lJ_IIIII LJ

(AREA CODE)

STAMPS RETURNED: ,l::;j

YES _ _ NA _ _ NO _ _

h 0

HOW MANY? _ _

aC:j

STATUS VENDOR liD

STORE NAME

Ulllll

VENDOR REPRESENTATIVE NAME

DATE PREPARED_/_/_ _

M
~

VENDOR TYPE
u(SWO USE ONLY)

STREET ADDRESS

CITY

STATE

ZIP CODE

~111111-11111

DIST/UNIT COUNTY

TELEPHONE

APPROVAL DATE

TERM DATE

TERM CODE

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 LJ

(AREA CODE)

STAMPS RETURNED: YES _ _ NA _ _ NO _ _
HOW MANY?~

ROUTING:

ONE FORM PER VENDOR

VIKING -ORIGINAL

L.A. -YELLOW

SWO-PINK

c;'1
> ~
(j "tt
:::0 0
(j
M
l::;j Cj
~
00
i ~ ~ ..c -...!
I
~
(")
~
:..:.s..
i
w I

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-4

VENDOR AGREEMENT

WIC- CsPECW. SIJPPLEMEN'IlOI. FOOO PIIOGIWIFOR-, JNF,\ICTS a CHII.E)RI;NJ

Page1ol3

VENDOR AGREEMENT

and This Vendor/Provider Agteement is made by

between the Georgia Oeparlment of Human Resources. Division ot Public Health, Health Dislrict

----,Unit

and-----=------------------ , (hereinafter lllferred to as the local Agenc:y)

(hereinafter referred to as the Vendor) to provide a mechanism lor the distribution of special ~tal foods to eligible WIC partic;:ipanls in the

counl}'1ies) included in this Health Oislrict Juris<fldion. This agreement will become effectM! o n - - - - - - - - - - - - - - - - - - -

and wiN terminate o n - - - - - - - - - - - - - - WIC VENDOR NUMBER

and and The undersigned represents the Vendor as the sole proprietor or the store The undersigned represents the local Agenc:y and has the authority to

manager to contract for

on behalf of the Vendor identified below. contract for on behalf ot said agency.

(Signature MUST be of owner or store manager.)

$q\;lture of s~ Owrte"J or Jr.bnaget

Dole

(Prmt) ~ of SIOte Owner ot M.'ll"'o-.ger

Name o1 \lf:nOot (Stcn)

MaillnQ Addtns Street P.O. Bolt

Street Loabott ot SIOte Street~

Cily

Cily

s....

ZC:l Code

~~ell~ Aqency Authon:ed ~M! IPrintJNamoo<lceal"-"" ....-!ted~..,
...... "'l.ocal"-""
M;hlinQ lrddre$$ $tteod P.O &o. Stale
T........... Numt>ef

Z"e>~

T~NutnbP.t

~ ol $~ Ooortr~et CH dtllerenl from abOve)

E!t~Wna:ted "4 01 FOOd Sales

Avet"agl!' Anrull Gtos3 Sales

M:llllo;l Address

~FootageoiStore

I Of Cz5h Regisler:s

City

StaiO

..... ~ F......,E._..,.,........._

"' - -
SocGISea.nty-

Notary Pubfic Signature and Seal

Date

Notary Public's Commission Expires

PURPOSE:

This Agreement is for the pUrpose ot providing a mechanism for the dislribMion ol certain listed foods to efogible participants and the redemption ot negotiable food instruments for the purchase ot said food items. The Vendor is retaiiled solely for the purpose set forth
herein and shall not be considered as an employee or agent of the Clepartment

lHE VENDOR HANDBOOK IS AN ADDENDUM TO lHIS AGREEMENT.

--

Form 3n1 (Rev. 796) Routing: White Slate V1C Office, Yellow Ux:al Agency, Pink - Vendor
VN -39

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-4 cont'd

VENDOR AGREEMENT
WIC VENDOR NUMBER

Page2of3

ntE RETAIL VENDOR HEREBY AGREES AND COVENANTS AS FOLLOWS:

A. To stock an adequate supply ol authorized types and brands ol WIC Program foods. in all categories. as determined by the Georgia wtC

Program.
a That all prices will be clearly marked either on the fOOd item or prominently displayed.

C. To pOSt the acceptable WIC Approved FOOds List in a consPicuous place by all cash registers.

D. To accept WIC vouchers for payment of the pUrchase of only eligible WIC foods (see Approved FOOds List). In addition. the vendor must

accept all valid WlC vouchers.

E. To accept no WJC IIOUChers as payment on past or present credrt account(s).

F. To accept no WJC IIOUChers from participants presented after thirty 130) d.1ys from the issuance date or prior to issue d.1te shown on the

voucher.

G. To accept only vouchers which contain a Georgia WIC Program SEAL

H. To refuse acceptance of any fOOd instrument on which any alreratrons have been made.

1. To sell WIC food items at or below the normal store shelf price. but not to exceed the maximum amount listed on the voucher (excluding
infant lormula voucners). J. To ~rmitWIC Program participants to purchase eligible fOOd items without making other purchases and to accord suchparticipants the same

courtesy given to other store customers.

K. To keep all inlormation conlidential on WJC particrpants.

L To direct QUestions concerning payment. program operations. etc.. to the Local Agency: participants will not be contacted concerning these

or other problem areas. (FOOd vendors shall not seek restrtution from Participants for vouchers not paid by the State.)

M. To ensure th.1t no exchange of money between the store and partrcipant takes place during a WJC voucher transaction.

N. To allow no rainchecks or exch.1nges of any IIOUCher for cash. credit. couPOns. stamps. premiums. or nonlisted fOOds; however. a Vendor is

net precluded from giving or accepting couoons. stamps. or premiums with pUrchases as if pUrChased with cash.

0. To obtain at the time ol pUrchase an original customer signature on the WJC voucher and re(!uest the participant to show a WJC identifrcation

card before the pUrchase of WlC fOOds can be completed. If the customer is unable to show a WJC identification card bearing the same

signature as signed on the IIOUCher. the Vendor should not accept the WJC voucher as payment for the fOOd(s).

P. To insert. in ink, the actual cost of the WJC fOOds on the WJC voucher face at the time of pUrchase in the presence of the customer.

0. To s:amp all vouchers with the authorized vendor stamp Iprovided by the Local Agency) before dePOsiting in the bank and to dePOsit all

WJC IIOUChers in a timely manner. preferably within fifteen ( 15) days of redemption but not more than sixty (60) days from the date o1

issuance shown on the voucher face.

R I. The owner 0t manager whO is legally responsible lor the store must sign the VendOt Agreement and shall anend aH mar.datory scheduled (Required) training

sessions fer wtC vendors. ol which _the Vendet win be notifred by the Local Agency. The owner Ot manager who receives WIC vendet training material via cer

tUied maa 0t anends any training session(s) will provide the infonnation received as training material for all their employees whO are involved in wtC program

participation, inCluding the checkout derks.



2. A vendOt owner Ot manager whO signs an authentic wtC Vendor Agreement/Contract in the absence ol a local or state agency WIC representative rTOJSt have

his/her Vendor Agreemeni!Contraa signed in the presence ol a Notary Pubfrc whOse Commission does not expire priet to the date that the Agreement/Contract

is signed. 3. A statewide unifetm PostTest shall be given to each vendor manager/owner/other store personnel during vendor training. to evaluate if objectives and guide-

fines set by the State wtC Agency were achieved. Therelete. each vendet manager/owner whO scores below the desired passing grade of seventy (70) shaD reschedule let additional training. in deficient areas. with the Local VIIC Agency representative.

4. To distribute to all employees involved in the Vendor's W!C Program participation aU communications received from the Local Agency pertinent ro lhe employee's Involvement in the WIC Program. To instruct cashiers. and all other employees, involved in the VendO<'s WIC P:-ogram participatioo o the eligible food and

the COtrect processing of WtC vouchers. 5. The Vendor wiU be accountable for actions ol employees in the utilization of vouchers Ot provision ol supplemental foods.

S. To abide by rules and regulations ol Federal. State and Local Agencies and all procedures as outlined in the Vendor's Handbook.

T. 1. That the State Agency may deny payments to the FOOd Vendor for improper fOOd IIOUChers or may demand refunds for payments

already made on improper food vouche1'S.

2. To reimburse the State Agency within thirty (30) days ol notifrcation for amounts paid by the State Agency on WlC Program fOOd

1/0UChefs processed by the Vendor which are above the normal shelf price ol foods.

U. To allow representatives ol the Local, State, or Federal />I;Jency to monitor the Vendor's store in an unanncunced manner at any time the

store is open for business. All records pertinent to this Agreement wil be made available for review by the representatille ol the agency.

V. That vendor stamps are the preperty ol the Stale ol Geotgia and that said st=.;:.;. wiil be returned to the WlC Program immediately upon

terminalion/suspension/disQualifrc:ation/voklntary withdrawal from program participation.

W. 1. That the vendor or the vendor's employee(s) wil not reimbu<se WlC participants or exchange WIC fOOd items, especially infant fonnufa,

when WIC 1/0UChefs were used for the pUrchase unlesS:

a Notified in writing by a health department representative.



b. The vendor is exchanging a WIC purchased ilem(s) due to inappropriately selling out-of-date WIC foods.

2. That any out-of-date foods wiD be removed from stocl< and replaced with foods that have expiration dates which do not exceed the

period ol normal expected usage.

X. That any Vendor disqualilied from another FNS Program shaH be disQualified from participation in the WJC Program for the same period of

time, up to three (3) years.

Y. A Vendor who commits fraud or abuse ol the program is liable to prosecution under applicable federal. state or local laws. Those who

have wiiHully misapplied, stolen, or fraudulently obtained WIC funds shall be subject to a fine ol not more than $10,000, or imprisonment

for not more than five (5) years. or both.

AA. To notify the Local Agency ol changes in management or when the Vendor ceases operation or ownership changes. This Agreement is null

and lrOid if ownership changes.

Aa State ol Georgia or Local Sates Taxes wiD not be collecled on food items pUrchased with WIC vouchers.

AC. To declare that neither the vendor/awner, the vendor's manager{s). or the vendor's olher emplcryee(s) is related by blood or marriage to

any W1C representative, unless otherwise revealed in writing, upon execution ol the contract/agreement or within the contract period. (space

provided on P3!le three ol this contract as:rreement for disdosure ol relatives).

AD. To visibly display the vendor's store name. as listed on the front page of this contract/agreement. on the outside of the store building/facility.

AE.. To abide by the U.S. Patent and Tradeti1arl< Laws. which prohibits unauthorized use o1 the W1C acronym and logo (refer to Registration ~mber 1,630,468, provided in 42 U.S.C. 1876, 15.U.S.C. 1051 et. seq. and 7 CFR Part 246).

Form 3nl (Rex. 7-96) Routing: White State WIC Office, Yellow Local Agency, Pink Vendor

VN-40

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-4 cont'd

VENDOR AGREEMENT
WIC VENDOR NUMBER

Page3of3

Name and Tolle ol rela!Ne that represents the Georgia WIC Program or employed by the Georgia WIC Program:

OffiCe address ol relative that represents the Georgia WIC Program or employed by the Georgia WIC Program:

Phone Number (office): ~~--'----------------
(Please attach additional page(sl if necessary)
II. THE LOCAL AGENCY HEREBY AGREES AND COVENANlS AS FOLLOWS:
A. To instruct the Vendor upon entry into the program of the appropriate procedures to process WIC Vouchers. B. To provide the Vendor with the current list of fOOdS appro-<ed lor disbursement to WIC Program participants and to issue updates to this
Food List as they occur. C. To provide educational material about the WIC Program to the Vendnr. D. To inslrucl WIC participants and proxies in proper use of WJC vouchers. E. To ensure that an authorized participant or proxy signature is affixed to any manual voucher prior to releasing the voucher lor redemption. F. To notify the Vendor with a copy of any changes in vouchers or use of vouchers and any changes in the federal and State Regulations
that may affect the Vendor. and to provide the Vendor with a copy ol any W:C regulation(s} or policy issuonce(s) affecting the Vendor's participation in the WIC Program. G. To assist the Vendor with any problem relating to the WIC Program. H. To provide the Vendor with a uniQuely numbered stamp.
Ill. BOTH PARTIES AGREE AND COVENANT AS FOLLOWS:
A. That no conflict of interest exists between the Vendor and the Local AtJerq (See Section 1.. AC.). B. Not to discriminate lor reasons ol age, race. color. sex, national origin or handicap. C. The Vendor has the right to appeal any deCision made by the Local ~ affecting the Vendor's abifity to participate in the WIC Program
under the terms ol this Agreement.
D. The period ol this Agreement is set forth on the signature page. New agreements wiU be executed each year. E. This Agreement shall become nuB and IIOid in its entirely upon any changes ol ownership ol Retailer.
F. This Agreement may be canceled by either party with thirty (30) days written notice. G. In the event ol termination of funds by the funding agency to the State ~ for the WIC PICgram. this Agreement terminates immediately.
H. That neither the Local /lqercf nor the Vendor haYe an obligation to renew the VendOr Agreerne<>t~ L This agreement/contract does not constitute a license or property interest. The relationship betWeen the local /lqercf and the Vendor
ends with the expiration dale clthis agreernenl/conlrnct.
IV. SANCTIONS AND APPEAl. PROCEDURES:
A. SANCTlONS Vendors shall be disQualified from WIC Program participation for a period o1 up to three (3) years if violations occur during a compliance pun:hase. monitoring visit by a WIC representative, or Food Stamp Program participation. Procedures for imposing the sanctions are outlined in the Retail Vendor Handbook. Any vendor disQualified from WIC participation may be cf1SQU31ifled from Food Stamp Program participation. Refer to 7 CFR 278.
B. APPEAL PROCEDURE Vendors are entitled to a fair hearing upon disQuafifJCation from the WIC Program. Any vendor reQUeSting a fair hearing must contact the
Local fV;jency by telephone. and contact the State WIC Offce in writing within fifteen ( 15) days alter the action which is oo;ng lal<en.
V. TERMINATlON POLICIES:
A. A Vendor shall be terminated from WIC Program participation if the store is ~licensed by the Georgia Department ol Agriculture. B. A Vendor shall be terminated from WIC Program participation if the store is not eligible lor Food Stamp Program participation/authOrization
or a Vendor is withdrawn from Food Stamp Program participation.
Form 3771 (Rev. 7-96} Routing: White State WIC Office, Yellow - Local Agency, pjnk VendOI'
VN -41

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-5

MILITARY COMMISSARY AGREEMENT

WIC Vendor ~areement Between l\1ilitary Commissaries and Local Agencies for
The Special Supplemental Food Program For Women, Infants, and Children (WIC)

.

e purpose of this WIC vendor agreement

s to outline the. basic res~~nsibili ties of

WIC local agenctes and mthtary commis-

saries which have been authorized to be WIC food

vendors.

I. 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 commis-
saries 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.

vouchers), acceptance of WIC 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 view 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) or 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.

J. 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

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 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

Part246).



Vendor Name (Print) Phone Number Signature ofAuthorized Military Personnel Date Signed

District/Unit

Vendor#

Signature of Local Agency Representative

Date Signed

VN -42

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-6

PHARMACY AGREEMENT

GeOt'l)ia Oepartnwnl of Human Resource'S Division ol Public Haith 'MC Pt-ogram
ISPECIAL SUPPl.EMENTAl. FOOD PROGRAM FOR 'NOMEN. INFANTS & CHilDREN)
PHARMACY AGREEMENT

Page 1 of 3

This Pharmacy/Provider Agreement is made by and between. the Georgia Department of Human ~esources. Division of Public Health. Heallh District

- - - - Unit

(hereinafter referred to as the LOCal Agency) a n d - - - - - - - - - - - - - - - - - - - - - - - -

(hereinafter referred to as the Vendor) to provide a mechanism for the distribution of special" supplemental formula to eligible WIC participants in the

county(ies) included in this Health District Jurisdiction. This agreement will become effective on - - - - - - - - - - - - - - - - - - - - -

and will terminate o n - - - - - - - - - - - - - - WIC VENDOR NUMBER

The undersigned represents the Vendor as the sole proprietor or the The undersigned represents the LOCal Agency and has the authority to pharmacy manager to contract for and on behalf of the Vendor identified contract for and on behalf of said agency.
below. (Signature MUST be of owner or pharmacy manager.)

$1gnatufe d Pharmac:y C>wneor or ~

o.,.

s.gn.,Jure 01 Local Agency Aufhorczed Re.,~hve

IPnntJ Name of Pharmacy Owner or M.1"""9C'

IPrantl N..vne oll.ocal /ltq!fY:y AuU'IQfiZf!d ~tatNe

~of Vendor CPharmacyl Mallir9 Address srreet P.o. Bo~:

N3fne. ol Local ~
Malhr9 Address - Stt-ee P 0. eo.

Slreer Location Clf Pharmacy Slreet Address

Cly

Cty

SUt

Z"<:tx~

......,.,.,.,._

State

Zoo<=-

,....,...,......,._

..
Cly

-- oe ~ Pharmacy~ 111 dif'ef~t trom ~-..) Slat<

Z<>Code

Eshn'Oited ..... ol Form..J.l ~k>s
~-else-
-
Fedefal EmPoyet ldentil~~er ~

A~:tqe At1nu.'ll Gloss $aln
ol CWt Registers
"' - -
Social S.C..Oy-

Nola!y Pubfic Signature and Seal

Date

Nola!y Pubfic's Commission Expires

PURPOSE:

This Agreement is tor the purpose ol providing a mechanism for the dislribtution of certain rested formula to efogible participants and
the redemption of negotiable food instruments lor the pUrchase of said formula items. The Vendor is retained solely lor the pUrpose set for1h herein and shaH not be considered as an employee or agent o1 the Department.

THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT

.oooRESS
Form 3782 (Rev. 796) Routing: White State WIC Office, Yellow Local Agency, Pink Vendor
VN -43

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-6 cont'd

PHARMACY AGREEMENT
WIC VENDOR NUMBER

Page 2of 3

THE PHARMACY VENDOR HEREBY AGREES AND COVENANTS AS FOLLOWS:

A Upon notifocation from the Local ~- to supply. within a time period agreed upon by the Pharmacy and the Local Agency. the necessary

supply of any one of the "Special Infant Formulas".

-_

a That all prices will be clearly marked either on the food item or prominently displayed.

C. To accept WIC vouchers for payment of the purchase of only eligible WIC formulas. In addition. the vendor must accept all valid WIC

vouchers.

0. To accept no WIC vouchers as payment on past or Pfesent credit account(s).

E. To accept no WIC vouchers from participants presented after thirty (30) days from the issuance date or prior to issue date shown on the

IIOUCher.

F. To accept only vouchers which contain a Geo<gia WIC Program SEAL

G. To refuse acceptance of any food instrument on which any alterations have been made.

H. To sell WIC formula at or below the normal pharmacy Shelf price. but not to exceed the maximum amount fisted on the voor.her (excluding infant formula IIOUChers).

To permit WIC Program participants to purchase eligible formula without making other purChases and to accord such participants the same

courtesy given to other pharmacy customers.

J. To keep all informa:ion contldentoal on wtt; partiCipants.

K. To direct QUestions concerning payment. program operations. etc. to the Local Agency: participants will not be contacted concerning these

or other problem areas. (Vendors shall not seek restitution from participants for vouchers not paid by the State.)

L To ensure that no exchange of money between the pharmacy and participant takes place during a WIC IIOUCher transaction.

M. To allow no rainchecks or exchanges of any voucher for cash. credit. coupons. stamps. premiums. or noni"ISied formula; however. a Vendor

is not precluded from giving or accepting coupons. stamps. or premiums with purchases as if pUrChased with cash.

N. To obtain at the time of purchase an original customer signature on the WIC IIOUCher and reQUest the participant to show a WIC identifiCation

card before the purchase of WIC formula can be completed. tf t~.e customer is unable to show a WIC identifocation card bearing the same

signature as signed en the \IOUcher. the Ver.dor should not accept the WIC IIOUCher as payment for the formula.

0. To inserL in ink. the actual cost of the WIC formula on the WIC voucher face at the time of purchase in the presence of the customer.

P. To stamp an vouchers with the authorized vendor stamp ( prO<Iided by the Local Agency) before depositing in the bank and to deposit all

WIC YO<ochers in a timely manner. preferably within fifteen ( 15) days of redemption but not more than sixty (60) days from the date of

issuance shown on the \IOUcher face.

0. 1. To distrit:.ute to all employees involved in the Vendors WIC Program participation all communications received from the Local ~

pertinent to the emptoyee"s Involvement in the WIC Program. To instruct cashiers. and all other employees. involved in the Vendor"s WIC

Program participation of the eligible formula and the correct processing of WIC IIOUChers.



2. The Vendor will be accountable for actions of employees in the utilization of vouchers or provision of supplemental foods.

3. A pharmacy owner or manager who signs an authentic WIC VendOr AgreemenVContract in the absence of a local or state agency WIC representative must have his/her Vendor Agreemeni/Contract signed in the presence ol a Notary Public whose Commission does not expire prior to the date that the Agreement/Contract is signed.

R To abide by rules and regulations of Federal. State and Local Agencies and all procedures as outlined in the WIC Pharmacy Handbook.

S. 1. That the State ~ may deny payments to tne Vendor tor tmproper food IIOUChers or may demand relunds tor payments already

made on improper vouchers.



2. To reimburse the State Agency within thirty (30) days of notification for amounts paid by the State Agency on WIC Program food

vouchers processed by the Vendor which are above the normal Shell price of formula.

T. To allow representatives of the Local. State. or Federal Agency to monitor the Vendor"s pharmacy in an unannounced manner at any time

the pharmacy is open for business. All records pertinent to this Agreement will be made avatlable for review by the representative of the

agency.

U. That vendor stamps are the property of the State of Georgia and that said stamps Will be returned to the WIC Program imme<foately upon termination/suspension/cfiSQUafifiCation/voluntary withdrawal from program participation.
v. 1. That the vendor or the vendor"s employee(s) will not reimburse WIC participants or exchange WIC formula. when WIC vouchers were

used for the purchase unless:

-

a. Notified in writing by a health department representative.

b. The vendor is exchanging a WIC purchased item(sJ due to inappropriately selling out-ol-<late WIC formula.

2. That any out-of-date formula will be removed from stock and replaced with formula that have expiration dates which do not exceed

the period of normal expected usage.

W. That any Vendor cfiSQUafifled from another FNS Program shall be disQualified from participation in the WIC 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

have willfully misapplied. stolen. or fraudulently obtained WIC funds shall be subject to a fme of not more than $10.000. or imprisonment

for not more than fiVE! (5) years. or both. Y. To notify the Local ~ of changes in management or when the Vendor ceases operation or ownership changes. This Agreement is null
and void if ownership changes. Z. State of Geo<gia or Local Sales Taxes will not be collected on formula items purchased with WIC vouchers. AA To declare that neither the vendor/owner. the vendor"s managet(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/agreement or within the contract period. (space provided on page three of this contract agreement for disclosure of relatives).

Aa To visibly cfiSplay the pharmacy"s store name. as tisted on the front page of this contracl/agreernent. on the outside of the store buildingllacility.

PC. To abide by the U.S. Patent and Trademark Laws. which prohibits unauthorized use of the WIC acronym and logo (refer to Registration Number 1.630.468. provided in 42 U.S.C. 1876. 15 U.S.C. 1051 el seq. and 7 CFR Part 246).

Fonn 3782 (Rev. 7-96) Routing: While Stale WIC Office, Yellow Local Agency, Pink Vendor
VN-44

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-6 cont'd

PHARMACY AGREEMENT
WIC VENDOR NUMBER

Page 3of 3

Name and Tille of relalive lhal represenls lhe Georgia WIC Program or employed by lhe Georgia WIC Program:

Offoce address of relalive lhal represenls lhe Georgia WIC Program or employed by lhe Georgia WIC Program:

Phone Number (office): '---....:'-~---------------

(Please allach additional page(s) Wnecessary)

II. THE LOCAL AGENCY HEREBY AGREES AND COVENANTS AS FOLLOWS:

A To instruct lhe Vendor upon enlry into the program of lhe appropriate procedures lo process WIC Vouchers.
a To ptOVide the Vendor with lhe current list of formulas apprO\'ed for disbursemenl to WlC Program participanls and to issue updates to this
Formula List as Ihey occur.
C. To provide educalional malerial about the WlC Program to the Vendor. D. To instruct WlC participants and proxies in proper use of WlC vouchers.
E. To ensure thai an authorized participant or proxy signature is affixed to any manual voucher prior lo releasing the voucher for redemption.
F. To nolify the Vendor with a copy of any changes in ..ouchers or use of vouchers and any changes in the Federal and State Regulations lhat may affect the Vendor. and to provide lhe Vendor with a copy of any WlC regulalion(sl or policy issuance(s) affecting lhe Vendor's participation in lhe WlC Program.
G. To assist lhe Vendor with any problem relaling lo the WlC Program. H. To provide the venctor with a uniQuely numbered slamp.

Ill. BOTH PARTIES AGREE AND COVENANT AS FOLLOWS:

A That no conflict of interest exists between the Vendor and the Local Agertcy (See Seclion I. AS.).
a Not to discriminate for reasons of age. race. color. sex. national origin or hancfocap.
C. The Vendor has the right to appeal any decision made by lhe Local Agertcy affecting lhe Vendor's ability to participate in the WIC Program
under the terms of this Agreement. D. The period of this Agreement is set forth on the signature page. New agreements win be executed each year. E. This Agreemenl shall become null and void in its enlirely upon any changes of ownership of Pharmacy. F. This Agreemenl may be canceled by eilher party wilh lhirly (30) days written nolice. G. In lhe ewnl of lerminalion of funds by the funding agertcy lo lhe Slate Agertcy for lhe WIC Program. this Agreement lerminates immediately.
H. That neither lhe Local Agency nor the Vendor have an obligalion lo renew lhe Vendor Agreement f. This agreement/contract does not constitute a license or property inlerest. The relalionship belween lhe Local Agency and the Vendor
ends with the expiralion date of lhis agreernenllconlract.

IV. SANCTIONS AND APPEAL PROCEDURES:

A SANCTIONS Vendors shall be diSQUalified from WIC Program participalion for a period of up to three (3) years if violations occur during a compfJance
purdlase. monitoring visit by a WIC representative. or Food Stamp Program participation. Procedures for imposing the sanctions are outlined in the WlC Pharmacy Handbook. Any vendor disQualified from WIC participation may be disQualified from Food Stamp Program participation.
Refer to 7 CFR 278.

a APPEAL PROCEDURE

Vendors are entitled to a fair hearing upon disQualifocation from the WlC Program. lvrf 'lender reQUesting a fair hearing truSt contad the

daYs Local Agency by telephone. and contact the State W1C Offoce in writing within fifteen ( 15)

after the action which is being taken.



V. 'TERMINATION POUCIES:

A A Vendor shaD be terminated from WIC Program participalion if the store is !iQI. licensed by the Georgia Department of Agriculture.

a A Vendor shaD be terminated from WIC Program participation if the store is not eftgible for Food Stamp Program participalion/aulhorizalion

or a Vendor is withdrawn from Food Stamp Program participation.



Fonn 3782 (Rev. 7-96) Routing: White State WIC Office, Yellow Local Agency, Pink Vendor

VN -45

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-7

VENDOR TRAINING CHECKLIST
Georgia Department of Human Resources Georgia WIC Program
VENDOR TRAINING CHECKLIST
I

WIC VENDOR NUMBER
I

1. _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-5) and the Vendor Handbook.)
2. Discussed purpose of the WIC Program. (See Vendor Handbook and Vendor Agreement.)
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-I.(D-I) and (M-Q).
7. Discussed checking out WIC customer and WIC I.D. Card. (Refer to the Vendor Handbook and Vendor Agreement-1.(0).
8. Discussed p2yment of WIC vouchers. (Refer to the Vendor Handbook and Vendor Agreemeilt-I.(T)( I) and (2).
9. Discussed procedure for processing bank-returned vouchers. (Refer to the Vendor Handbook.)
I0. Conducted in-depth discussion of compliance monitoring and sanctions. (Refer to the Vendor Handbook and Vendor Agreement I.(S) and IV.)
II. Discussed purpose of Vendor Agreement and who is authorized to sign the agreement. (Refer to the Vendor Application Booklet and Vendor Agreement page-! of 3 and I.(R)( 1).
12. Read and discussed each item listed on the Vendor Agreement.
13. Discussed how to contact Local and State WIC 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-I.(RX2).
15. I have received a copy of the Vendor Handbook and Sanction System and the content of the information provided in each document was discussed.

YES 1 .__I_N_o_...JI I NtA 1

16. Other{Specify) - - - - - - - - - - - - - - - - - - - -
l acknowledge in-depth discussion or the Vendor Handbook, the WIC Vendor Agreement, and all other items checked "Yes" as outlined by the Vendor Training Checklist above.

Comments=-----------------------------------------------------------------

OwncriMan:~ger

Name OwncriMan:Jget (PRINT)

Name or Vendor (Store)

Mailing Addn:ss..strecl. l.ocalion, P.O. Box

City

Stale

Date Zip Code

Loc:ul Agency Authorized Representalive

~..cal Agency Authorized Repr=nt:ltivc (PRINT)

Local Agency Authorized Repr=nt:llivc

~..cal Agency Authorized Repr=llt:llivc (PRINT)

N:unc or Local Agency

Mailing Addn:ss - Stn:el, Location, P.O. Box

City

State

Date Date
Zip Code

Fonn 3757 (R.,., 7-96)

ROUTING: White- SWO Yellow-District Pink-Vendor

VN-46

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-8

VENDOR TRAINING INFORMATION FORM
GEQRGL4. DEPARTMENT OF HUMAN RESOURCES
Georgia WIC Program
VENDOR TRAINING INFORMATION FORM

DISTRICT _ _ _ _ _ _ _ _ UNIT

=-------DATE _ _ _ _ __

LOCATIONOFTRAINING _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

TRMNlliGCONDUCfEDBY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

LIST OWNER/STORE MANAGER WHO DID NOT ATTEND ANNUAL TRAllilliG AND VENDOR AGREEMENT WAS NOT RENEWED.

(TO BE TERMINATED)

VENDOR#

. VENDOR NAME

NUMBER OF STAMPS RETRIEVED

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: WHITE- STATE WIC OFFICE YELLOW- DISTRICT
VN -47

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-9

VENDOR TRAINING SIGN-IN SHEET
Ckor:gia Department ofHuman Resources DMS!ON OF PUBUC HEALTii WICOFF!CE
VENDOR TRAINING INFORMATION FORM
SIGN-IN SHEET

DISTRICT_ _

UN1T_ _

DATE._________________________

TYPE OF TRAINING: ANNUAL 0 FOLLOW-UP 0 :MAKE-UP 0 OTHER'-----------------
LOCATION OF TRAINING:_____________________________________________

TRAnnNGCONDUCTEDBY:___________________

VENDOR NUMBER

STORE NAME

PRINT OWNER/MANAGER NAME

SIGNATUREffiTLE

FORM37S6(Rev. 1-96)

ROUTING: WHITE-STATE WIC OFFICE YELLOW-DISTRICT OFFICE
VN-48

GA WIC PROCEDURES MANUAL FY '97 VENDOR HANDBOOK

Attachment VN-10

Georgia
WIC
Vendor Handbook
Georgia Department of Human Resources
FFY 1997

Georgia VVIC Program
VN -49

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 0 cont' d

VENDOR HANDBOOK

Contents

WhatisWIC

\\,1C approved food list

1

What foods can a W!C customer

(panicipant) purchase

2

Minimum inventory requirements

2

The W!C food vouchers

3-4

Processing WIC vouchers

4

Checking out the W!C customer

5

Imponam notes

5

Voucher payment policy

5-6

Voucher payment procedure

6

Vendor Training

6

Compliance performance

6-7

Sanctions, disqualifications, and terminations

7-9

About the W!C acronym and logo

10

Termination procedures

10

Hearing/appeal procedures

10

Change of ownership

10

Changing store location

10

Where to get more information

10

How to read the vendor profile

11

Incident/complaint form

12

Vendor review form

13-16

W!C transaction repon

17

VN -50

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

What Is WIC?
W C stands for Women, Infants, and Children. The WIC program is funded by the U.S. Depanmem of Agriculture and is administered in Georgia by the Depanment of Human Resources through state, district, and local health offices.
WIC provides imponant food to pregnant women and their infants and/or young children. Proper nutrition at the

beginning of life may help prevent serious health problems. WIC gives children a chance to grow up healthy and lead active, productive lives. WIC program panicipams have been examined by health professionals who determine the need for supplemental food and nutritional guidance.
The panicipants receive vouchers for specific kinds of highly nutritious foods. These vouchers are redeemed by panicipating grocers or pharmacies (vendors) who have signed an agreement to follow all WIC program requirements.

Food Item

\VIC Approved Foods List

The following list of foods may be purchased using WIC vouchers:

Brand or Type

Container/Pkg Size

Cannot Buy

Milk (Pasteurized) Cereal
Cheese

Whole, Skim. 99% Fat Free. or low Fat (2%) (least Expensive Brand Only)
Acidophilus, Enjo): l.actaid,l.aaaid 100. Nutrish or Dairy Ease. Evaoorated. Powdered or UHf :'.iilk
Cheerios, Chex (Com. R!ce, or Whe:u), Crispy Criuers. Country Com Flakes, I<ix. Nabisco Quick Cream of Wheat (Regular flavor), Produa 19,Jim Dandy Quick Grits (!ron Fonikdl, Minute 3 Brand Instant Oauneal (Regular ~-or), Harvest Instant Oatmeal (Regular p..,orl Quaker Instant Grits or Oatmeal (Regubr Flavor). Tool Com Flakes, Kelloggs Special Kor Com Flakes Kelloggs Complete Bran Flakes. Quaker Sun Country Quick Oats (Regular Fbvorl, Quaker Oats Crunchy Com Bran Ralston: Optima 100 Whole \Vbeat Flakes, Enriched Bran Flakes, Nutty Nuggets, Instant Oatmeal <Regular Flavor). Crispy Rice, Corn Flakes. Tasteeo/Toasted Oats, Crispy Corn Puff
'R2lston S<ore &.nels ADcv,.,d: Krog<r, !Country FI<Sh. IGA. R<d 6:: White FI:a...ontc or NatureS Best
American (lndividu.lly 'M2pped or Unwr>pped Sli<cd or Block), Cheddar (Biockl, Colby (Block), Moruern:y]ack<51ockl Mo=rella (Biockl

One Gal. Size ONLY (Exception: lJ2 u..l. -~-Qts. cof Enjoy, lactaid, and/or Addophilus, 12-0z Cans Evaporated, 3 or 5 Qt. Boxes Powdered. 8 Oz box UHT Milk)
Nine (9) Oz. Sizes and Above ONLY
Can purchase more than one (1) type/brand of cereal as long as the amount does not go over the quantity on the front of the voucher

Flavored Milk, Buttermilk. or Goat'sMUk
Eight (8) Oz. or less Size Boxes

Nine (9) Oz. Up to 16-0z (One [l] Pound) Size ONLY

01eese Food, Shredded or Deli Cheese, and/or 2-8 Oz Pkgs. for 1-16 Oz Pkg (no 8 Oz Pkgs of Cheese)

Juia:(lOO% USRDA Vttamin C. Fortified)

Orange: I.= Expcnsh-. Br.nd Only
Grapefruit: Last Expcnsr.-. Bl2nd Only
Grape: Welch's orJuicyJuice-White Grape: WelchS"' Seneca Apple: Fbvorue.l..uclcy tc.!. s..Jl. Shur FlllC, Kroger, Sen= (R<d LabeO
Thrifty Maid, Whi1< House, Juicy Juice
Other: Dole: O=g<!Pincapple, OnngciPincapplci!!anana
Pincapp~Pinopp~MandamcTmgcmc
Mounl2!n Cheery, Ordwtl Peach, Country Raspbcny. Tropw:al Fruit,
Pil1capplcJGEapCfru~
juicy juice: ~ Pun:h, !ropial. Sti3Wbcny. Applc!Gr.tp:. Otangc Punch,Bcny

46-0z Cans. 6 Oz. Cans or 12 Oz. Cans Frozen ONLY

Juice Drinks, Fresh Squeezed Juice, Single SMJg. Sizes. Infant
Juices, Juices With Sugar Added

Eggs (Gr.uic: A la!ge ONLY Dried Pe3SI'Beans Canned Pc:as'Be:ans

least Expensive Brand Only Any Brand Without Flavoring Added Any Brand Withour Flavoring Added

One (1) Dozen One (1) Pound Size ONLY 15 Oz Cans ONlY

Any Other Size/Qnty. Any Other Size/Qnty. Any Other Size/Qnty.

Peanut Butter Infant Fotmula Infant Cereal (Boxes Only)
-

Any Brand Without Jelly Added or Honey Spread As listed on the Front of the Voucher Beech Nut, Gerber, Heinz

18 Ounce Jars ONLY As I..isted on Front ofVoucher Dty Cereal in 8 Oz. Sizes ONlY

AnyO!her Size/Qmy.
Unlisted on \bucher
A.rrj Baby Food injais cr Any Dty Cmal with Fruit/ Formula Added

lima

W.Uer Packed ONlY

6 118 Ounce Cans ONLY

lima Packed inOil

Carrots

Fresh, Whole, Canned-Medium Cut

One(l) lb Presealed Plastic Bag - Bulk. Frozen.

or 15 oz. Canned Slice:!

Shredded. or BabyCmocs

l
VN- 51

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

, What Foods Can a \VIC Customer (Participant) Purchase?
The WIC participant may become a regular cus-

tomer at a participating store and purchase any groceries there. However, the WIC 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 W!C 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

Size

Number of

Types/Brands

Milk: (Pasteurized)

20

1 GaL Jug

1 Brand

Note: Quanity may includp w~ole. 2%, 1%. and skim milk in the gallon size conitainer only.

Cheese:

16

1 Lb.pkg.

2 Types

Eggs: (Grade A Large)

16

1 Doz.eggs per canon

1 Brand

juice:

24

46 oz. can

12

12 oz. frozen container

2 Types 2 Types

Cereal:

30

9-20 oz. box

Note: At least two (2) types of cereal must be in 12 oz. size.

4Types

Peas/Beans:

8

I lb. pkg.

2 Types

Peanut Butter:

8

18 oz. jar

2 Brands

Formula:(With Iron)

186"

13 oz. can

1 Brand

Contract brand of formula only. Vendor must be able to supply soy, powdered, ready-to-feed, concentrate, Lacto Free

or a different brand of formula upon request.

Vendor must stock a minimum of 32 cans of Prosobee (so!J base Contracted brand) formula, 16 cans of Lacto Free

(lactose reduced Contracted brand) formula and 138 cans o Enfamil (milk base Contracted brand) formula.

Note: Low iron formula does not meet WIC minimum inventory requirements for formula.

Infant Cereal:

12 I

Note: At least one (1) type of infant cereal must be rice.

8 oz. box

2 Types

Pharmacies arc exempt from the minimum inventory requirements. but must 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: Enjoy, Lactaid, Nutrish, Acidophilus, Lactaid 100, Dairy Ease and UHT Milk.
CHEESE: Nine (9) oz. to one (l) pound package(s) of cheese only, no eight (8) oz. packages of cheese are allowed to be purchased.
JUICE: Only twelve (12) oz. containers (frozen), six (6) oz cans, and forty-six (46) oz. cans ofjuice 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.

2
VN -52

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 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).
If a vendor experiences difficulty selling specific \VIC approved food item(s), then the vendor may write to the Local Agency or State WIC Office to request a minimum inventory waiver from stocking the hard to .;eJl irern(s). The State \VIC Office will determine if a vendor meets the waiver criteria.
The WIC food vouchers
The voucher for WIC foods is a check and should

be redeemed just as carefully. When a voucher is properly redeemed, 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 WIC vouchers, so he/she must be sure that they know all WIC voucher redemption requirements. The state and local W!C offices can assist with cashier training as needed.
A W!C vendor must accept all valid \VIC vouchers. However. no voucher will be redeemed for more than the maximum amount printed on the face of each voucher.

There are three types ofWIC vouchers, computer generated, standard manual, and blank manual.

Computer generated voucher: All information on this voucher is computer printed.

DEPARTMENT OF HUMAN RESOUR~S

32845232

F\11Y lO ll-1!;; ORDER Of' ANY AUTHORIZED GEORGIA W1C VENDOR
~ lMXtra.ICiLIMm'rc:tCN.Y-1110 ~
F~:PACXACE-QII...... W.CttE:It COD 031
-Ut.K: 1 &M. ......._if ez cas Eu~
-:.ICM U~ eT ectX c:ttt:~s: UP TO 1: LB
. .lttiCE: 112 azCM FRON 0 l-4~ CZlC. .

YOUR BA.BY NEEDS SHOTS AT 2 MONTHS. 4 MONTHS. ~tS~ECT~

II loiOHTHS, 15 MOHtltS, A 5 YEARS

STATE JHJ FEDE1W.

PROS(arnt)N

Standard manual voucher: Manual vouchers are processed in the same manner as computer generated vouchers.
The standard manual voucher has the name, !.D. number and dates written or typed by the staff at the clinic.

VN -53

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 0 cont'd

VENDOR HANDBOOK

, Blank Manual Vouchers
The blank manual voucher has the name, !.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 for the amount of food indicated. Only one (1) number should appear in each box.

Examples:
0 I. [Z] Correct U 2. ~ Correct

0 0 Incorrect 0 ~ Incorrect

Xs 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 detailed in the Vendor Newsletter, which is distributed to vendors quanerly.

IT./I.HT/a.NC

wtCIONO.

c

PAF!nc:FANT

ASH ARSTOAY

lOUSE

I.ASTOAY
I T I I I I lOUSE

Yi Go7ml~J~ o~.!J!~~!~l~t" PAY TO THE OROER OF ANY AUT><ORIZEO ClEORGlAWir.-vi'NooR

><l<JC>EA NO.
~9459203

~ THEK "Vol$ I CIUNd1'T'IES c>f.T- ICJ $W$TnVnOH5

e-. ~- .... tj jFOAM<.U

~COO
11~W

.w...w...

l..ua:

oOGozCono 'C2o.zc../FI'D\.

'CiozC..Conc.

VENDOR MUST
DePOSIT BY
,., ,.... ....

E::.:::::::.:::: I~<" ~ ::!: : :. rn~---__-__~ jEGGS

II II Co2

'12oz<=-E..,.

\_

..)

:::=... I>Cono-

IPEASIIIEAHS I I .. """'

"Ga ......... -

fax!

co:..-T--
_I
V ~_I_LI

I \PEAWTIIU1"TtR I .. .. .. ..
1-A I ,.,...c... CARROTS

NPROPEA USE ~ THS

-J

VOOOER IS SUB.JECl TO
sr.ne """~'EDFW.
PROSECVTtON

l

"" ........._
tl) fl'irnl~ poqo

Tt V......u I u I._.

-

- -~- .. J - - -

.....

'

~ n"Ci'1lc511 20311" :m, oooo ?B: 00 01:,3 oou '-

- - -- -

J ...,

Processmg WIC Vouchers
After a grocer has 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 stamped 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 Nations Bank of Atlanta, Georgia.
Payment will be assured, prior to the deposit, if:
l. A WIC program authorization seal appears on the face of the voucher(s).
2. An authorized WIC vendor stamp appears on the face of the voucher.

4. The amount of purchase does not exceed the maximum amount printed on the face of the voucher.
5. The panicipant 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 leftcomer (for manual vouchers only) and right-corner of voucher(s). The panicipant must sign the area "Sign Here at WIC Office," prior to redemption of manual vouchers and/or sign a voucher register for redemption of computer-generated vouchers. In addition, the area "Sign Here at Gro~ eery Store," should be obtained upon redemption ofWIC food item(s).

3. A total amount of the purchase is entered in the All vouchers which do not meet these require-

presence of the customer.

ments will be returned unpaid to the vendor

4
VN -54

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

Checking Out the WIC Customer
When food is purchased with a WIC \oucher, the cashier must do the following: 1. Check the customer's WIC identification card for
the proper WIC ID 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 ID 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 WIC Office). 3. Check the dates on the voucher. Vouchers cannot be used before the "First 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 the shelf price or price on item(s) ofWIC food(s) for each voucher. Make sure that the exact types and amounts of approved WIC foods are being purcha:;ed. 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/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 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. 8. If the WIC customer cannot sign his/her name, the WIC customer must make his/her 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 his/her mark.
IMPORTANT NOTES Any WIC customer who attempts to purchase foods that are not approved or creates other problems in the store should be reponed 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 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 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. If a manager is called to approve a WIC voucher transaction, it is imperative that the customer is not identified as a WIC participant over the public address system. Every effort must be made to protect the confidentiality of the participant/proxy. and discussion of the transaction should be kept at a conversational level. Provisions Lj. and LK. of the Vendor Agreement state that WIC participants must be accorded "the same courtesy given to other store customers", and store personnel must keep all information confidential on WIC participants." 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 WIC customer should arise. (See page 12 for a copy of the Incident/Complaint form.) Food purchased with a WIC voucher cannot be returned for a cash refund. (Cashiers should write "WIC" on receipts given for food purchased with WIC vouchers). Failure to give a receipt for WIC purchases is a category II sanction violation. 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.
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 cashiers initials.

5
VN -55

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

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 vendors shelf price(s) up to, but not over, the "not 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 vendors Federal Employer Identifier (FE!) number or Social Security Number (SSN) if the FE! 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 vo<.Icher 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) m\}!;t 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 vouchers will accompany the form. No payment will exceed the voucher "not to exceed" maximum. Payment on vouchers received without the form (3760 ) will be delayed.
Vendor Training
Vendor training will be conducted to inform vendors of the appropriate program policies and procedures pertaining to WIC vendors in the following ways. l. Initial Authorization Training:
The Local Agency will provide training upon initial authorization of each WIC approved store. 2. Initial Authorization Follow-Up Training:

Within thirty (30) days of authorization the Local Agency will conduct an on-site monitoring/training visit on each newly authorized vendor. If the store is not stocked with the required minimum inventory of perishable and non-perishable WIC approved foods at the time of the visit, the vendor shall receive sanctions. 3. Required Subsequent Training: (Failure to attend these trainings will result in vendor contract termination.) The store Owner/Manager who is legally responsible for the store. shall attend all scheduled required training sessions for WIC vendors, of which the vendor will be notified by the Local or State Agency. (These trainings are reqttired at a minimum of once per Federal Fiscal Year.) .. 4. Subsequent Training: The State Agency/Local Agency will conduct onsite training for WIC vendors personnel at the request of the store owner/manager.
Compliance Performance
The performance of every 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. (See pages 13-16 for a copy of the Vendor Review Form.) 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 policies and procedures compliance, merchant training needs, 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 of WIC food items for a period of two (2) years. Compliance performance The performance of every vendor is monitored carefully with computer reports on each WIC voucher transaction. Compliance investigauo9~ shall be conducted in authorized WIC vendors store$. Vendors identified for investigations will consist of those vendors that are considered to be potentially high risk by system

6

VN -56

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

repons and those vendors who have been reported to the WIC Program for potentially violating program regulations. Non-potential high risk vendors will be randomly selected for investigation. Investigators shall shop with WIC Vouchers to determine whether a store is complying with WIC program requirements. A WIC transaction report will be completed after each visit to the vendors store. (See page 17 for a copy of the WIC Transaction Report).
Vendors will receive Vendor Profile sheets on an annual basis. (See page 11 on how to Read the Vendor Profile Report). Any vendor identified as being 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 sanctions according to the Georgia WIC sanction system. In addition, redeemed vouchers are reviewed by the State Agency and repayment will be requested for vouchers exceeding the vendors shelf price. Notification of investigation results will be given within 14 working days of the investigation.
Vendors not involved in a current investigation will be notified of other administrative sanction 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 by the expiration date on the current agreement will be terminated and the vendor 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: l. Store must have the minimum required inventory
of WIC foods at all times as described in the Vendor Application Booklet. Physical inventory must be viewed by the WIC representative(s) at the time of the vendor review visit. Proof of order of food items shall not be accepted. (See page 2 for minimum requirements and pages 8-9 for sanction system) 2. Store shelf prices for WIC 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 Department of Agriculture and eligible for Food Stamp Program authonza.,L:;u.. 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 sanction consistent with the severity and nature of the violation. (As per federal regulation 246.12 (K) (1), the Georgia WIC Program has taken into account the severity and nature of violations in establishing the Sanction Point System). Each violation of program policy and/or regulations has a specific time period during which the sanction(s), waming(s), probation, or disqualification will remain on the vendor's record. In addition, a vendor shall be disqualified from WIC Program participation if disqualified from Food Stamp Program participation or terminated if no longer licensed by the Department of Agriculture.
All sanctions/warnings earned are retained
on the vendor file for a period of one year.
Sanctions/warnings will "roll off' one year
from the date of receipt.

Disqualifications

When a vendor accumulates the maximum number

of warnings and/or violates program policies and/or

rules/regulations during a probationary period, the

store shall be disqualified from the WIC program, with the exception of hardship cases to WIC participants or

probation ofWIC vendors. This could resitlt in disqualification from Food Stamp Program participation.

The period of disqualification is determined by the

severity and nature of the violation, the number of"Yjo-

lations, and past disqualifications. The actual disqu31-

ification periods are determined using the same crite:

ria for every vendoi:.



Vendors will receive Vendor Profile sheets on an

7 VN- 57

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

~nnual basis. Any vendor identified as potentially high risk will be investigated by the State WlC Office. If the vendor is found to be in violation of program policies and regulations through an investigation, he/she will be assessed sanctions for violations occurring in each investigative visit or will be disqualified according to the sanction system.
Vendors not involved in a current investigation will be notified of sanctions as they are assessed or assigned.
The nature and severity of a violation shall determine the sanction assessed and the period of disqualification. Disqualification from the WIC Program may also result in disqualificati()n from the Food Stamp Program. If a vendor is disqualified from Food Stamp Program panicipation the vendor shall be disqualified from WIC Program panicipation for the same period of time, up to three (3) years. (Refer to WIC Program Federal Regulations 7CFR; Pan 278)
Probation Period for Hardship Cases
If disqualifying a vendor causes hardship to WIC panicipants, the vendor shall be granted a probationary period. In hardship cases, a probationary period can be granted only once per authorized WIC vendor. A hardship case is granted only when the nearest authorized vv1C 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 from the date of modification regarding the violation(s).
The following is a description of the sanction system and how it works:
Sanction System
The following is a description of the sanction system and how it works: A. Category I- Two warnings for offense(s), third of-
fense probation for six (6) months, fourth offense in category I, II, or Ill disqualification for six (6) months L Stocking a WIC food item(s) outside of manufac-
turers not-to-exceed date(s). 2. Prices not marked clearly on WIC food items or
nearWIC food items. 3. Allowing WIC food items to exceed the quantity
specified on the voucher. (Except for promotional items)
B. Category II- Warning on first offense, second

offense probation for eight (8) months, third offense in category I, II, or III disqualification for eight (8) months 1. Failure to repay overcharges based upon specific
computerized repons. 2. Failure to properly process vouchers at the store
(this includes failure to calculate [ring up] sales of WIC purchases; not writing price on ;,.::urber before panicipant signs). 3. Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or more WIC food items (types anc:l/or brands). (Physical inventory must be viewed by a WIC representative at the time ofvisit. Proof of order of food items is not acceptable). 4. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items. 5. Allowing purchase of similar anc:l/or non-similar food items in exchange for WIC vouchers (this includes allowing substitutions for food items listed on WIC vouchers; substitution of one WIC food item for another; allowing the purchase of WIC foods in unauthorized container sizes). 6. Failure to remain open for business at least eight hours per day, six days per week. 7. Failure to give a receipt for WIC purchases.
C. Category III -Warning on first offense, second offense probation for ten (10) months, third offense in category I, II, or III disqualification for ten (10) months l. Discrimination 2. Issuing rain checksi!OUS. 3. Contacting WIC panicipants for any reasons regarding a WIC transaction. 4. Requiring panicipant to pay cash to redeem WIC vouchers. 5. Allowing the purchase of any formula other than the one specified on the front of the voucher.
D. Category IV- Warning for first offense, second offense probation for twelve (12) months, third offense in category I, II, III or V disqualification for twelve (12) months, third offense in category
IV or VI disqualification for three (3) year.;
L Overcharging on WIC vouchers (charging for foods not received or charging in excess ofshelf price or item cost for food listed on the voucher) during a compliance purchase investigation.
Any Violation From Category V or VI That Occur At Any TIIDe Will Result In Immediate Disqualification

8

VN -58

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

For The Period Specified In Category V or VI

Example 1:

E. Category V- Immediate disqualification for twelve (12) months for each violation 1. Intentionally providing false information on vendor records.

lst

2nd

Warning [warning

Letter

Letter

3rdLetter 8 month Probation

Fmal letter 8 months disqualification

E Category VI- Immediate disqualification for three (3) years (thirty-six months) for each violation 1. Failure to provide vouchers or inventory records upon request. 2. Transacting \VIC vouchers outside of the \VIC auth orized fixed store location. 3. Failure to allow monitoring by \VIC representatives. 4. Accepting or purchasing vouchers from unauthorized stores or other unauthorized sources. 5. Providing non-food items in exchange for \VIC vouchers. 6. Providing cash in exchange for \VIC vouchers. 7. Conviction of a felony related to store operations.

Category !category

I Offense I Offense

#I

#2

Category II Offenses #2 and #5

Category
m
Offense
#2

Category II Offense #3

Category! Offense #3 (Violation occurring during probation)

Vendor violations will be categorized by the severity
and nature of the offense. Each category has a pre-
scribed period of disqualification, probation, or warnings assessed. Warnings remain active on the vendor case Hie for a twelve (12) month period. A vendor found to be in violation within the probationary period shall be disqualified for not less than the full probationary period or not more than three (3) years. Probationary periods are granted by the State WIC Office and are not subject to a fair hearing. Vendor will continue to operate his/her business during the probationary period. Ifa vendor is disqualified from Food Stamp 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 Stamp Program Federal Regulations 7CFR; Part 278). Disqualification will not exceed three (3) years.
Disqualification from the WIC Program may also
result in disqualification from the Food Stamp Program.

Example 2:
1st Warning Letter
Category
I Offense
#2
Category II Offenses #1 and#4
Category ill
Offense #1

2nd Warning Letter 8month Probation
Category II Offense #3

3rd Letter Immediate Disqualification for three (3) years
Category VI Offense
#4

As per Federal Regulation 246.12 (k)(l), the Georgia WIC Program has taken into account the severity and nature ofviolations in establishing the Sanction System.

About the WIC Acronym and Logo
The acronym "WWC was registered with the U.S. Patent and Trademark Office on january I, 1991, Registration Number 1,630,468. Authority to use the "WlC: acronym and the logo are provided in 42 U.S.C. 1876, 15 U.S.C. 1051 et seq., and 7 CFR Pan 246. Therefore, this

9
VN -59

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

cotice is to inform you that Food and Consumer Services Office of the United States Department of Agriculture reserves the right to approve any uses of the \VIC acronym, and any uses that are considered inappropriate shall be discontinued.
Vendors who wish to receive approval or denial
regarding wrc vendor authorization must submit a
completed WIC application form 45 working days prior to store opening or change of ownership. All retail vendors will be subject to the same application process. W!C vouchers must not be accepted by vendor applicant during the application process.
Terminations
l. If a vendor voluntarily withdraws from WIC program participation, the owner must: a. Notify the local \VIC agency of their decision. b. Return the Vendo: Stamp(s) to the local WIC agency.
2. If a vendor decides to sell a business (store), the owner must: a. Notify the local WIC agency of transaction. b. Return Vendor Stamp(s) to the local WIC agency immediately.
3. A vendor shall be terminated from WIC Program participation if the store is not licensed by the Georgia Department of Agriculture.
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.
Contract/Agreement Termination Policy
Shelf prices (on WIC approved foods) of the vendor must be compatible with other stores 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 two (2) written notifications, from the State WIC Office, will result in termination of the vendors agreement thirty (30) days after the second notification. Vendors scheduled for termination will receive an opportunity to sign a Contract addendum, stating that the vendor agrees to lower his/her prices on specified WIC items, to avoid termination. (The policy, procedures and specific addendum stipu-
10

lations are detailed in the current Georgia WIC Proce-

dures Manual in the VN section under

Termination/Disqualifications. Exceptions will be

made if vendor termination creates WIC participant

hardship (refer to page 8, Probation Period for Hard-

ship Cases).



Hearing/Appeal Procedures
Vendors are entitled to a fair hearing upon disqualification from the W!C Program. Any vendor requesting a fair hearing must contact the local agency by telephone and contact the State W!C Office in writing
within fifteen (15) days of the adverse action.
Sale/Purchase of Store or Change of Ownership
Upon the sale of a \VIC-authorized store and the purchase of a previous \VIC-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. Vendors who wish to receive approval or denial regarding WIC vendor authorization must submit a completed 'WIC application form 45 working days prior to store opening or change of ownership. All retail vendors will be subject to the same application process. WIC vouchers must not be accepted by vendor applicant during the applica-
tion process.
Changing Store Location
When a store moves to a new location but is still under the same management, the local WIC agency
must be notified of the address change immediately.
Where to Get More Information
Local WIC offices can offer help to vendors if questions or problems arise. Most WIC offices can be contacted through the county health department. The State WIC Office in Atlanta can also provide assistance. To contact the State WIC Office, phone or write to this address. (Please have your WIC vendor number available when calling or listed when Writing):
Georgia Department of Human Resources State WIC Office
Two Peachtree St., N.W., 8th Floor Atlanta, Georgia 30303 (404) 657-2900 or call the WIC Hot line 1-800-228-9173

VN -60

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

EXAMPLE VE~'DOR PROFILE ***Vendor Information***

Vendor Number: Vendor Name: Activity Date: District Unit: Vendor Type: County:

0482 Mom and Pop Mini-Mart 07/31/96 51 2 116
***Volume ofBusiness ***

Vouchers Paid (Current Month):

553

$ Amount Paid (Current Month):

5,603

Vouchers Paid- Fiscal Year To Date:

3,558

$Amount Paid- Fiscal Year To Date:

67,084

%Vouchers Exceed Fiscal Year 6 Month Average:

10.4

#Vouchers Exceed 6 Month Average:

52

% ofTotal DIU Vouchers:

3.3

% of County Vouchers:

82.7

# Vouchers Outside Vendor Area:

2 I 0

$ Amount earned for vouchers received outside Vendor Area: 2,092

%Vouchers Outside Vendor Area:

38.0

# Vouchers Paid Last 6 Months:

6

5

4

3

2

1

524

473

500

497

492

519

***Vendor Scores (07/96: Federal Fiscal Year 1996) ***

A B CI C2 EI E2 E3 F G H I M N 0 p Q TOT

95 98 8 0 IOO 0 0 I I 0 8 0 38 0 3 20 392

X X

X

665 686 23 0 Il25 0 0 I2 I2 0 60 0 266 0 3 I20 2972

VN- 61

District/Unit/Clinic:_ _ _ __ County:,_ _ _ _ _ _ __ Date of Incident:,_ _ _ _ __ Date Reported:_ _ _ _ _ __ Follow-up Date Person Flllnu Complaint Name: Address:
Phone:( )
Incident/Complaint:
i
0\ N
Local Agency Resolution:

GEORGIA DEPARTMENTOP IIUMAN RI:SOURCES
WICPROGRAM
INCIDENT/COMPLAINT FORM

~u!ldnant lnf!I[WB!I!!n Name: Guardian:
WIC l.D. Number: DOB: Phone:( )

Vendor lnf!lrmallon VendorNendor #: Employee Name:
Title: Phone:( )

Stale WIC Office Resolution/Comments:

Follow-up Report:

SWO Customer Service Coordinator:

FORM 3771 Revised l/95

Routing: Orlglnlai-State WIC Office, Yellow-District WIC Office, Plnk-WIC Clinic

Type of Complaint;
Participant [ 1
Vendor []
Local Agency/State WIC Office Staff[ 1

1&~111 AUtD!:XlSIB!~ m~
lnforma!l!!D

Staff Name:

Phone:{)

'~
z
~
,0:;o

!,::>J::

Signature:

~

~

Can Complaint be Closed at Local

''o0

Agency?

~

Yes( I No( I

Signature and Title: Date:
Can Complaint be Closed at State WIC0ffice7
Yes( I No( I

Signature and Title:

I

Date:

I

Date:

~
~
(')
~
::0
0
(')
M
~
~
00
i
t"'l
~
~
\0 -....l
I
i
..I...
0
(')
0
~
0...

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

Georgia Department of Human Resources
Division of Public Health WIG Program
VENDOR REVIEW FORM

Vendor Number

Page 1 of 4

District

Unit

Date of Visit

I

I

Vendor Name

Store Owner

Street Address

City

Review Type

Q Vendor Self Review (attach to Vendor Application)

Q Pre-Approval Visit (Non-perishable Food Review) Q

Q New Vendor (not applicable as yearly visit)

Q

Yearly Visit Follow-Up Visit

Store Manager County

I Zip Code

Q Minimum Inventory Wajver Granted 0 Regular Minimum Inventory Required

Note: Physical Inventory must be viewed by WIC representative at the time of visit. Proof of order of food items shall not be accepted.

A.

Minimum Inventory Requirements

Juice:

1. Are there at least 24 cans of 46 oz. size juice in stock? If no, how many cans? _ _

2. Are there at least 12 cans of 12 oz. size frozen juice in stock? If no, how many cans?_ _

3. Are there 2 types eac!1 of frozen and canned juice? If no, how many? Cans _ _ Frozen _ _

4. Was price marked on juice or posted on the shelf/dairy case?_ _

5. Was juice within date limit? If no. how many were not? Cans _ _

Frozen _ _

Yes

No

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Apple
Grape: White Grape: Orange: Grapefruit Other: Cole
Juicy Juice

Brand Name Fiav-o-rite Kroger Juicy Juice Lucky Leaf Seneca (Red Label) Shur Fine Staff Thrifty Maid White House Juicy Juice Welch's 100% Welch's Seneca Least expensive only Least expensive only Pine-Orange-Banana Pineapple-Orange Pineapple-Passion-Banana Pineapple-Orange-Guava Mandarin Tangerine Mountain Cherry Orchard Peach Country Raspberry Tropical Fruit Pineapple-Grapefruit Cherry Tropical Punch

NIS

Prices: 46 oz. NIS Prices: 12 oz. Frozen

$

$

$

$

$

$

s

s

s

$

s

s

s

s

s

s

$

$

$

$

$

$

s

$

$

$

s

s

$

$

$

$

$

$

$

s

s

$

$

s

$

$

s

$

s

$

$

$

$

$

$

$

$

$

$

$

Strawberrv Aoole-Graoe

$

$

'

$

$

Oranoe Punch

$

$

Comments on Juice:

Berry

$

$

Form 3774 (Rev. 7-96)

Routing: White - State Wic Office Yellow - Local Agency Pink Vendor
VN -63

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VEN.DOR HANDBOOK

Vendor Number
Cereals: (At least two types in 12 oz.. sizes) 1. Are Illere at least 30 boxes of 9 oz. to 20 oz. size of cereal in stock? If no. how many?_._
2. Are ltlere at least 4 types of WIC cereal in stock? If no. how many? _ _
3. Are ltlere at least 2 types of 12 oz. size boxes of cereal in stock? If no. how many? _ _
4. Was price mar1<ed on cereal or on shelf? 5. Was cereal wiltlin date flmit? If no. how many were not? _ _

Cheerios

NIS

Oz. Size

ComChex

Rice Chex

WheatChex

Country Com Aakes

Crispy Critters

Kix

Kellogg's Com Aakes

Special K

Product 19

Total. Com Flakes

.

Harvest Instant Oatmeal (Regular)

Jim Dandy Quick Grits (Iron Fortified)

Minute 3 Brand Instant Oatmeal Plus Oat Bran (Reaular)

Nabisco Quick Cream of Wheat (Regular)

Quaker Instant Grits (OriqinaJ)

Quaker Instant Oatmeal (Regular)

Kellogg's Complete Bran Blakes

Quaker Sun Country Quick Oats (Regular Aavor)

Quaker Oats Crunchy Com Bran

Ralston: Optima 100 Whole Wheat Aakes

Enriched Bran Aakes

NultY Nuggets

Instant Oatmeal (Regular Aavor)

CriSpy Rice

ComAakes

Tasteeo/Toasted Oats

Crispy Com Puff

Ralston Store Brands Allowed: l<rogt!r. Kountrv Fresh. IGA. Red & White. Aavorite or Nature's Best

Comments on Cereal:

Peas/Beans 1. Are ltlere at least 8 bags of 16 oz. size peas/beans in stock? If no, how many?_ _ 2. Are ltlere at least two types of peas/beans? If no. how manyt__
3. Was price marked on peas/beans, or on shelf?

Brand

Type

NIS_ _

Comments on Peas/Beans

Page 2 of 4

Yes

No

0

0

0

0

0

0

0

0

0

0

Highest Prices
s s
$
s s s s s
$
s s s
$
s s
$
s
$
$
s
$
$
s
$
s s s s

Yes

No

a

0

0

0

0

0

Highest Prices

s

s

Peanut Butter: (No peanut butter/jelly combinations or Honey Spreads)
1. Are ltlere at least 8 jars of 18 oz. peanut butter In stock? If no. how rnanv2--

NIS __

Yes

No

0

a

. -

2. Are ltlere at least two brands of peanut butter? If no, how many'Z.__
3. Was price marked on peanut butter, or on shelf?

Highest Price $

and

.
Brand of Peanut Butter

0

0

0

a

Comments on Peanut Butter:

Form 3774 (Rev. 7-96)

Routing: White State WIC Office Yellow Local Agency Pink Vendor

VN -64

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

Vendor Numl:ler

Page3of4

Infant Cereal: (At Least one type of cereal must be rice) 1. Are there at least 12 boxes of 8 oz. size of infant cereal in stOCk? If no. how many boxes?_ _
2. Is rice cereal in stOCk? 3. Is there one other type. other than rice, in stOCk?
4. Was price marl<ed on cereal or on shelf?
s. was cereal within current date limit? If no, how many were not?_ _

Yes

No

a a

a a

a a

a a

a a

Brand and Price of Infant Cereals: Beechnut
Gerber Heinz

Rice (Highest Price) $ _ _ _ _ __
s _____
s ______,.

Other (Highest Price)

NIS

$ _ _ _ _ __

$ _ _ _ __

s

Comments on Infant Cereal: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-l

t-nrm"'"~- n"<m.mum of 32 can of contracted soybase, 138 cans of milkbase and 16 cans of lactoFree Formula) Are there 138 cans of 1~ oz. concentrate milk based contracted formula with Iron in stock? If no, how many? Are there 32 cans of 13 oz. concentrate soy based contracted formula with Iron in stock? If no, how many?_ _
Are there 16 cans of 13 oz. concentrate LactoFree contracted formula with Iron in stock? If no. how many?_ _ Is fom...'!:! "!ithin current date limit? If no, how many cans were not? _ _ Was price marked on cans or on shelf?

Yes

No

a a

a a

a a

a a

a a

Milk: (Minimum of 20 gals. whole milk, 2%. 1% & skim milk of the least expensive brand)

1. Are there at least 20 gals. of milk in stock? If no, how many?__

NIS _ _

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:

and

Brand of Milk

Comments on Milk:

Cheese
1. 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 shelf/dairy case? 4. Was cheese within date f11t1i!? If no, how many were not?_ _

Highest Prices of Cheese: American S - - - NIS - - Colby S

NIS --Cheddar

NIS

Monterey Jack$

NIS _ _ Mozzarella S - - - NIS - -

Yes No

Q

a

a a

a

Q

Yes No

Q

Q

Q

Q

Q

a

Q

a

Comments on Cheese:

Eggs: (l.east Expensive Brand) 1. Are thereat least 16doz. Grade A Large eggs in stOCk? If no, how many? _ _ 2. Was prie!! marKed on eggs or posted on the dairy case? 3. Were eggs wi!hln date funit? If no, how many were not?_ _

Lowest Price: $

and (Grade A Large)

NIS _ _

Brand of eggs

Yes No '

Q

Q

Q

a

Q

a

~entsonEg~---------------------------------------------------------------1

Form 3774 (Rev. 7-96)

Routing: White - State Woe Office Yellow - Local Agency Pink - Vendor

VN -65

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK
Vendor Numbe.___ _ _ _ _ _ Page 4 of 4

8. ParticipanWendor Observation (Not applicable for pre-approval) 1. Were any WlC vouchers on hand in 1tle store? If Yes, were all voucher amounts filled in? - -
It 1tle voucher amount is not filled in, list 1tle voucher number(s) in 1t1e comments section 2. Observed WIC participant making a purchase? It Yes, were appropriate procedures followed? _ _
Explain inappropriate procedures:

Yes No NA

Q

Q

Q

Q

Q

Q

Comments
C. General Questions/Observations 1. Does 1tle store need to be referred to 1tle 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 observed? 4. Is 1t1ere a need for additional training at this time? 5. Are all price columns for foods not in store marked N.I.S. (Not in Store). This answer must be yes.

Yes

No

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

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 WIG representative, unless otherwise revealed in writing, upon execution of the contract/agreement or within the contract period. The results of this monitoring visit have been discussed with me and I understand the violations (if applicable) that were found and the food prices listed above are correct.

Signature of Vendor Representative

Date: _ _ _ _ _ _ _ _ _ __

Pt1nt Name of Vendor Represenzative
I have discussed all findings, any violations and training needs (if applicable) with the appropriate vendor representative.

Signature of WIC Representative

Date=-----------

Print Name of WIC Representative
D~--------------U~--------------Vendor Representative C o m m e n t s = - - - - - - - - - - - - - - - - - - - - - - - -

WIC Representative Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Fonn 3774 (Rev. 7-96)

Routing: White State Wte Office Yellow local Agency Pink Vendor
VN -66

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-1 0 cont' d

VOUCHER NUMBER
STORE NAME AND ADDRESS:

VENDOR HANDBOOK
Georgia O<!partm<!nt of Human Ruourc.,; Division of Publi< H<!alth WKProgram
WIC TRANSACTION REPORT (WTR)
WTR RETURNED TO W1C AGENCY:

VENDOR NUMBER

1. 1, - - - - - - - - - - - - - - - - - - ' R<!presentativ<! of WIC Program, Department of Human Resources, mak<! the fonow;ng statement fre<!ly and voluntarily, knowing that this stat<!ment may be used in evidence.

2. On (date)

at about (time)

1entered the subj<!ct store. I select<!d the items SP<!Cified below.

At th<! ch<!ck-out counter there (was/were) -.J>"rson(s) in lin<! ahead of me and _ _ _ P<!rson(s) in lin<! behind me. Th<! clerk sold to
me the items fisted below at a total cost of (if available) s_ _ _ _ _ _ _ _ _ _.

1used the WIC food instrument indicated above. The price of the item(s) was marked on the item(s) or shelf indicated below.

During ch<!ck-out. th<! vouch<!r was in plain view of the cl<!rk who s<!rved me. For those items not priced marked, th<! price was verified by

3. Tim<! Entered Store 4. CHECKLIST
Prices Marked on Food(s) or Sh<!ff Wrote Price on Vouch<!r
5. COMMENTS:

Yes No
0 0 0 0

Approached Checkout
Rang Up Sa le!Ca lculated Identification Card Checked

Yes No
0 0 0 0

L<!ft Store
Substitution of WIC Foods Gave Receipt to Investigator

Yes No
0 0 0 0

OESOUPTION OF Q.ERK (APPROXIMATE}

1.SEX _l2.RACE

IJ.AGE

7. OTHER IDENTIFYING INFORMATION

,4.HEIGHT

JS.WEIGHT

6. HAIR COLOR
8. IDENTIFIED DURING TRANSACTION AS
(NAME)
nn.E. Rfi.ATIONSHIPTO OWNER

EUGIBLE ITEMS
QUANTITY

SUMMARY OF PURCHASE
BRAND NAME

9. MEANS OF IDENTIFICATION ITEM

INEUGIBLE ITEMS
QUANTITY

ITEM

PRICE

ITEMS DJ:S:t I<:J:n
QUANTITY
Form3773 (R<!V.11-92)

ITEM

IREPRESENTATIVE SIGNATURE

ROUTING

WHITE COPY STATE WIC OFFICE

IDATE
YELLOW COPY- LOCAL AGENCY

VN -67

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-10 cont'd

VENDOR HANDBOOK

Standardsfor participation in the WIC Program are the same for everyone regardless ofrace, color, national origin, age, sex, handicap, religious or political
belief

irJ
DHR GEORGIA DEPARTMENT OF HUHAN RESOURCES
State WIC Program Unit
Two Peachtree St., N.W:, 8th Floor Atlanta, Georgia 30303 1-800.;228-9173
Form No. 3783 (Revised 6-96)

VN -68

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-11

CASHIER TRAINING PAMPHLET

Cashier Training Pamphlet
FFY 97

WIC - Special Supplemental Food Program for Women, Infants, and Children
Georgia Department of Human Resources
VN -69

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-11 cont'd

CASIDER TRAINING PAMPHLET

A Grocery store cashiers are the most impor-
tant part of the WIC voucher redemption process. It is the responsibility of the cashier to make sure that the WIC vouchers are within the proper date limits, that a signature appears on the left side of a manual voucher, that a WIC Program authorization seal appears on the face of the voucher(s), and that the WIC customer receives the correct WIC food items. We hope that the following information will help the cashier to process WIC vouchers in the appropriate manner.
What is WIC?
\VIC stands for \Vomen, Infants, and Children.
WIC provides important food to pregnant
women, infants, and young children.
WIC program participants have been exam-
ined by health professionals who determine 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.
Processing WIC Vouchers
The WIC voucher is similar to a check and should be redeemed just as carefully.
There are three types of WIC vouchers: computer generated, standard manual, and blank manual
1

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2

VN -70

Standard Manual Voucher: Manual vouchers arc processed in the same manner as computer generated vouch-

>C1

ers. The standard manual voucher has the name, I. D. number, and dates written or typed b~ the staff at the clinic.

~

~
(j

~""'

(j

~

t::1

~ ..... ,

~
f/:1

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.-..........).

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~ Blank Manual Voucher
o'IIMT/ClNO

PARTICIPANT

flSN

VOUCHER NO.
: 9459203

FIRST DAY TO USE
LAST DAY TO USE
VENDOR MUST DEPOSIT BY

>""'

~

~
""'::r:::
~
M
~

FOOD PACKAGE CODE jFORI.M.A

OJ I FOR ntESE ITMS I OUAHTITIE$ Of.a.V -NO SOBSTIJVTIONS

\IOUCHER CODE

jjcEREAL

or hlant

JUICE

13 o.z Cans Cone.
32 oz Cana Ready lo Feed
i-4 or 16 01: Cans Pcmdcred lb Cens ~lranYg60
POII&gen Pregcstinil
WI.-- Type_ Form

or M.<t

!cHEESE !was

I lbs I I D<n

[Pf'AStBEANS

I

I 'PEANUT OUTTEn

lb D<led
)4)1o18oJ

J jr~~.. _._ I._~_liB or Cens

~ ~6orCMS

E:i!;!l---- 12 01 C8na/f'rzn.

i l ____ j

F

IMPROPER USE OF THIS

VOUCHER IS SUOJECT TO

STATE ANOFEOEnAL

PROSECUTION

:og, 1r0ooo ?a: 00

.. ~- ...... ... 11193

.
~
()
~
l,.:..l..
i
..I..... .......
()
0
l,.:..l.. 0:

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-11 cont'd

CASHIER TRAINING PAMPHLET

A

Blank Manual Vo ...-.::her: 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 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:

QJ 1. [8] Correct

02.

~Correct

0 [2J Incorrect
0 ~ 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).

Checking out thfl WIC Customer

'When food is purchased with a \VIC voucher, the cashier must do the following:

L Check the customer's \VIC identification card for the proper \VIC ID 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 WIC ID card.

2. For manual voucher(s), check to see if the voucher has been signed (once) by ~e 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."

4. Separate the food listed on the vo~_cher from

other purchases, if the WIC customer has not

doneso.



5

5. Ring up the shelf price of the food for each voucher. Make sure that the exact types and amounts of approved \VIC 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/prm:y 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 \VIC ID card. If the customer's name does not appear on the ID card, do not accept the voucher.
8. If the \VIC customer cannot sign his/her name, the \VIC customer must make his/her 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 \VIC customer also signed the ID card with his/her mark.
Important Notes:
Any \VIC 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 \VIC Office immediately.
\VIC 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 checkout lines for \VIC 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 discriminatory. However, grocers who wish to ensure that WIC, participants do not enter certain lines,
6

VN -72

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-11 cont' d

CASHIER TRAINING PAMPHLET

such as express lines, may post "Cash Only" signs in those lines.
If a manager is called to approve a WIC vouch-
er transaction, it is imperative that the customer is not identified as a \VIC participant over the public address system. Every effort must be made to protect the confidentiality of the participant/proxy, a-nd discussion of the transaction should be kept at a conversational level. Provisions I.]. and I.K. o; t!1':! Vendor Agreement state that \VIC participants must be accorded "the same courtesy given to other store custom~rs," and "store personnel must keep all information confidential on WIC participants."
\VIC customers may not receive change from
VVIC voucher purchases or credit in exchange for VVIC vouchers.
VVIC customers may not be contacted regard-
ing any payment problems with WIC vouchers. Contact the local WIC clinic if a need to contact a WIC customer should arise.
Food purchased with a WIC voucher cannot be returned for a cash refund. (Cashiers should write "WIC" on receipts given for food purchased with WIC vouchers). Failure to give a receipt for WIC purchases is a category II sanction violation.
The customer may not use a WIC voucher to purchase any item not listed on the WIC voucher.
The \VIC customer must never be required to pay any additional cash for items purchased with the WIC voucher. A VVIC voucher can not be redeemed for more than the maximum purchase price listed on the front of each voucher. If a voucher is rejected by the bank, the voucher with an explanation on the return voucher payment log, should be sent to the State WIC Office for reimbursement.
7

WIC APPROVED FOODS LIST

FOOD ITEM (BRAl\'D or TYPE)

NOT ALLQ\\'EO

MILK: {Posteurizcd): I Gd Size 01\"LY Whole, Skim, 99% FatF=(1%),Low Ft(2%)
{Lost Expensive Br:~nd 0:'-.1.Y)
.-\cidophilu.<, Enjo\', U=id,U.:aid 100, ~'UTRISH, D2iry E.asc (112 0..1 or Qt 0:'-."LY)
E,.,por-:otcd (12 Oz C.ns 0:'-."L\) Po,.dered(3 od QcBoxcs0:'-.1.\) UHT Milk (8 Oz Box)

CA!\1'-:0T BUY, F!.-'Ored Milk Buttcnnilk C'><nt'sl\1ilk

CEREAL: (9 Oz Siu:s or Abovt:-Can Mix Size/Types) ~'"NOT Bt..'Y,

Chccrios

Chex..("..om. Rice. or \\1lc::u.

Cri:qw Critters

~ ( )z. ur Sm21lcr Boxo

Couricrv Com Fbkcs

1-Urvc:si Insane O..m10l (Rq!' Fl:.\ur)

Jim O.ndy Quick Gri"' (Iron Fortified)

Kix

::..:'2hisco Cram of\\'hot (Regubr Fbvor)

3 minute Bnnd lnscnt O:Jonc:2l (Rq;ulu Fb\'or)

Product 19

Qu:lkc< Insane Gri"' (RCllllbr fb,-or)

Qu.ker Insane O.ane2l (ltcgubr fb,-or)

Toci-Com Fl>kes,

Kellogg's SCI K or Com Fbkcs, Kdlogg's

Comptete r.an Fl:akeS

Qulier Sun Countn Quick 021S (Regubr fb,-or) Qu.kcr 0.1S Cruncliv Com Br:~n

!Uisto"' Optim~ HlO Whole Wheat Fbkcs, Enriched Br-an F12.kes, ~utty ~~ Insant Oaane2l ~r Fl:;wor). ~~tf Com l=bkes, T.stceo!Toasn:d ts, Crispy

. .~-...._........_.~."-''lrYF...._IC".A..LdA:\\"""~ ~.a.:.

CHEESE(9-16 Oz{llb} SizcsOI\"LY) .J..meric::m lndhidwllv v.Tap~d or un"'nppcd
(Sliced or Block)
Colb,(Bio<:k) ,\loniere\'Jack (Block) Mo=rcll (Block) Cheddar (Block)

C..._,'l':OTBUY,
Chccsc Food Shredded Ch=c DdiCho:c: 2-~ Oz Pkgs for 1-16 Oz
Pk!?
Any ROz or S=ller Pkg>

JUICE: (100% USRDA Viwn.in C Fortified. 46 Oz Uns, CA.''l':OT BUY,

6 Oz C=s or 12 Oz Frozen C=s 01\1.Y)

juice Drinks

GRAPE: Welch's orJuicyJuice

!n&mjuiccs

WHrrE GRAPE: (Welch's or Scnca)

ORANGE: I...st Expcnsh-e Br-and O~"LY

Fresh Squeezed Juice

GRAPEFRt..'lT, Lost Expensive Bnnd 0:'-.'LY

Single S.::n-ings

Juices "ith Sug.r Added

APPLE: Fl'"orite. Kroger, LucL-y Lc2f

JUICY JUICE

Scneo (Red I..:..bel Only), SalT, White House

OTHER

Dole: Or>ngc/PinC2pplc, Onngc/Pinc::~pplc!Bnan>

PinCilppie/P:.~.ssion/B:aruru, Pine:applc/Or:mge/Gw\":1

M.2nd.2.rin T.zngerine. Mounain Cherry. Orchard

Pc2ch, Country !Uspbcny. Tropic! Fruit.

PinC2pplc!Gnpcfiuit

Juicy Juice, Chen;-. Punch, Smwbcrry. Tropia!, Bert)"

Applc!Gnpc, Or:~nge Punch

EGGS: (Grade A I...:a::E"- I Dz Size 0!\"LY)
Lc:tst Expcnsn'C Br:~nd Only

~'NOT BUY, !my Ozhcr Size!Qu.ntity

DRIED PEAS/BEANS: (I Lb S"1Ze Paclage) Canned Peas/Be:ms: (IS 0z Can) Any Br:and Withoat Fbvorin~: Added

CA!\1'-:0T BUY, Any Ozhcr Size!Qu.ntit)

PEANUT BUI'TER: (18 OzJars 0!\"LY)
Any Bnnd WithoacJeUy or Honey Spread ll\'FM'T FORMtJLA: As Listed on Front ofVouchcr

CA!\1'-:0T BUY: Any Ozhcr Size!Qu.nticy
CA!\NOTBUY,
f'JnY~rv~~~ on

ll\'FM'T CEREAL: (Dry, 8 Oz Boxes 01\"LY) Beech Nur. Getbcr. Heinz

CA!\1'-:0T BUY: Any]"()(" DlyCcrc21 ,.;th Fruit or FonnUb Added

TIJNA, (6 Oz C=s 0!\"LY) W2t<:!'P2dced
CARROTS: (1 Lb Pre-Scaled l/lasDc ~Or 15 Oz Conned Sliced Fresh. Whole, Canned edium Cut

CA.''NOT BUY: Oi!P2dced
CA!\NOT BUY
Bulk. Frozen, UMcd
Shredded. 0< B2by

VN -73

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-11 cont'd

CASHIER TRAINING PAMPHLET

Standards for participation in the WIC Propam are the same for everyone regardless ofrace, color, national origin, age, sex, handicap, religious or political belief

illDHR
-OEPAIITHEHTOI'
HUMAHRDOWa:s
Georgia WIC Program Division of Public Health Two Peachtree Street, 8th floor Atlanta, Georgia 30303 1-800-228-9173
Form No. 3791 (Revised 6-96)
VN -74

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-12

..
RETURNVOUCHERPAYMENTLOG
TO: Georgia WIC Office
Two Peachtree Street, N.W., 8th Floor Atlanta, Georgia 30303

RETURNVOUCHERPAYMENTLOG

FROM:

(Corporate Office/Store Name)

(City. State, Zip Code)

(STATE WIC OFF1CE USE ONLY)
REASON NOT PAID CODE: 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 "Last Day to Use" date D. Signature of Participant missing E. Exceeded Maximum Amount Allowed

VENDOR NUMBER

VOUCHER NUMBER

AMOUNT

-

Vendor (or Representative) Signature

(Date)

Fonn 3760 (Rev. 5/95)

ROUTING: White. Yellow. and Pink- State WIC Office; Gold-Vendor
VN-75

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-13

POST VENDOR TRAINING EVALUATION

GEORGIA WIC PROGRAM POST VENDOR TRAINING EVALUATION
FORM FOR FFY '97 ANSWER SHEET

Page I of2

WIC VENDOR NUMBER------- DISTRICT UNIT _ _ __ TEST SCORE---STORE NAME AND N U M B E R - - - - - - - - - - - - - - - - - - - - - , , - - STORE REPRESENTATIVE'S N A M E - - - - - - - - - - - - - - - - - - - - - -

I.

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

2.

How many cans of Enfamil (with iron) must be on your store shelfdaily?

a.

77-13 oz. cans

b.

138~13:oz. cans

c.

I86~tfoi. Ca.ns

3.

How many cans of Prosobee must be on you store shelfdaily?

a.

16-13 oz. cans

b.

32-13 oz. cans

c.

77-13 oz. cans

4.

Juice can be purchased in ______A'-'----- and ______c""---- sizes only.

a.

6 oz. and 12 oz.

b.

64 oz. jars and 46 oz.

c.

12 oz.:froze~ 46 oz. can, and 6 oz. can

5.

Which ofthe following Juicy Juice flavors are WIC approved?

a.

Apple-grape, orange punch

b.

Berry, cherry, punch

c.

Grape, tropical

d.

All ofthe above

6.

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 participant for the $2.55

b.

Write the purchase. am<!unt at.or below. the ~Uffi:Jui~:~f:!.2~QO.

7.

If you have a problem with a WIC voucher from a WIC participant, who should you contact?

a.

The WIC participant

b.

The1.iocalWie.Office or the State WIC Office.

c.

Noneofthe.above.



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. 1>,:

c.

Form 3795 (Rev. 8/96)

Routing: White -STATE WIC OFFICE
VN -76

Yellow- LOCAL AGENt:Y

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-13 cont'd

POST VENDOR TRAINING EVALUATION

POST VENDOR TRAINING EVALUATION FORM FOR FFY '97 (PAGE TWO) ANSWER SHEET

Page 2 of2

9.

A WIC participant gives you a voucher that has a ''Maximum purchase price must not exceed" $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

I0. What must you do with a voucher that is rejected by the bank?

a.

Place voucher(s) in drawer for two (2) months, then call the WIC Office.

b.

Immediately send the original voucher(s) and completed voucher payment log to the State WIC Office.

c.

Ask the participant to pay the amount that exceeds the voucher maximum.

II. Cashiers must not accept WIC vouchers from other States.

a.

True

b.

False

12. The cashier(s) must not charge sales tax for WIC purchases.

a.

True

b.

False

13. WIC requires a minimum inventory of sixteen (16) one (I) pound packages of cheese in two (2) types.

a.

True

b.

False

14. A receipt must be given to the WIC participants/proxies for WIC purchases.

a.

True

b.

False

15. Food purchased with WIC vouchers can be returned for cash refund?

a.

True

b.

False

16. Would you ring up WIC items with other non-WIC item purchases?

a.

Yes /

b.

No

17. If your store was out ofKix 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

18. The cashier must check _ _ __,0<----- when processing WIC vouchers.

a.

authorized person(s) signarure(s)

b.

the Participant's WIC ID number

c.

all dates

d.

a, b/aild c

19. The WIC participant must sign the WIC voucher(s)

B

by the cashier.

""''

the "pay exactly" area has been completed

a.

before

p:

!f!~

20. Georgia WIC vouchers are _ _ _ __,C:-.._ _ _ _ in color.

a.

peach

b.

green

e;.

l:).~~~~<,l:.~b,ite

Form 3795 (Rev. 8196)

Routing: White STATE WIC OFFICE

Yellow- LOCAL AGENCY

VN -77

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-14

VENDOR REVIEW FORM

Georgia Department of Human Resources
Division of Public Health WIC Program
VENDOR REVIEW FORM

Vendor Number ______________ Page 1 of 4 District---------- Unit - - - - - - - Date of VISit

Vendor Name

Store Owner

Street Address

City

Review Type

a ..Vendor Self Review (attach to Vendor Application)

a a Pre-Approval Visit (Non-perishable Food Review) Yearly Visit

cl New Vendor (not applicable as yearly visit)

a Follow-Up Visit

Store Manager
- --
County

I ZipCode

a Minimum Inventory Waiver Granted a Regular Minimum Inventory Required

Note: Physical Inventory must be viewed by WIC representative at the time of visit Proof of order of lood items shall not be accepted.

A.

Minimum Inventory Requirements

Juice:

1. Are there at least 24 cans of 46 oz. size juice in stock? If no, how many cans? _ _

2; Are there at least 12 cans of 12 oz. size frozen juice in stock? If no, how many cans?_ _

3. Are there 2 types each of frozen and canned juice? If no, how many? Cans _ _ Frozen _ _

4. Was price marked on juice or posted on the shelf/dairy case?_ _

5. Was juice within date limit? If no, how many were not? Cans _ _

Frozen _ _

Yes

No

a a

a a

0

a

a

0

0

0

Apple
..
Grape: White Grape: Orange: Grapefruit: Other: Dole
Juicy Juice

Brand Name Flav-o-rite Kroger Juicy Juice Lucky Leaf Seneca (Red Label) Shur Fine Staff Thrifty Maid WhiteHouse Juicy Juice Welch's 100% Welch's Seneca Least expensive only Least expensive only Pine-Orange-Banana Pineapple-Orange Pineapple-Passion-Banana Pineapple-orange-Guava Mandarin Tangerine Mountain Cherry Orchard Peach Country Raspberry Tropical Fruit Pineapple-Grapefruit Cherry Tropical Punch

NIS

Prices: 46 oz. NIS Prices: 12 oz. Frozen

$

$

$

$

$

$

$

$

$

$

s

s

s

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Strawbeny

$

$

Apple-Grape

$

$

Oran(le Punch

$

$

Comments on Juice:

Berry

$

$

-

Form 3774 {Rev. 7-96)

Routing: White - State Wic Office Yellow - Local Agency Pink - Vendor
VN -78

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-14 cont'd

VENDOR REVIEW FORM

Vendor Number
Cereals: (At least two types In 12 oz. sizes)
1. Are there at least 30 boxes of 9 oz. to 20 oz. size of cereal in stock? If no. how many? _ _ 2. Are !here at least 4 types of WIG cereal in stOCk? If no. how many? _ _ 3. Are there at least 2 types of 12 oz. size boxes of cereal in stock? If no. how many? _ _ 4. Was price marl<ed on cereal or on shelf? 5. Was cereal within date limit? If no. how many were not? _ _

Cheerios

NIS
..

Oz. Size

ComChex

Rice Chex

WheatChex

Country Com Flakes

Crispy Critters

Kix

Kellogg"s Corn Flakes

Special K

Product 19

Total, Com Rakes

Harvest Instant Oatmeal (Regular)

Jim Dandy Quick Grits (Iron Fortified)

Minute 3 Brand Instant Oatmeal Plus Oat Bran (Reqular)

Nabisco Quick Cream of Wheat (Regular)

Quaker lns1snt Grits (Original)

Quaker Instant Oatmeal (ReQular)

Kellogg's Complete Bran Blakes

Quaker Sun Country Quick Oats (Regular Flavor)

Quaker Oats Crunchy Com Bran

Ralston: Optima 100 Whole Wheat Flakes

Enriched Bran Flakes

Nuttv Nuggets

Instant Oatmeal (Regular Aavor)

Crisov Rice

Com Rakes

Tasteeo/Toasted Oats

Crispy Com Puff

Ralston Store Brands Allowed: Kroqer, Kountrv Fresh, IGA, Red & White, Aavorite or Nature's Best

Comments on Cereal:

Peas/Beans
1. Are there at least 8 bags of 16 oz. size peas/beans in stock? If no, how many?_ _ 2. Are there at least two types of peas/beans? If no, how many?_ _ 3. Was price marl<ed on peas/beans, or on shelf?

Brand

Type

NIS_ _

Comments on PeasJBeans

page 2 0 f4

Yes

No

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Highest Prices $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Yes

No

Q

Q

Q

Q

Q

Q

Highest Prices

$

$

Peanut Butter: (No peanut butter/jelly combinations or Honey Spreads) 1. Are there at least 8 jars of 18 oz. peanut butter In stock? If no, how many2_ _
2. Are there at least two brands of peanut butter? If no, how many2_ _
3. Was price rnarl<ed on peanut butter, or on shelf?

Highest Price $

an"

Comments on Peanut Butter:

Nls __ Brand of Peanut Butter

Yes Q Q Q
-

Form 3n4 (Rev. 7-96)

Routing: White -State Wic Office Yellow- Local Agency Pink - Vendor

No Q ' 0 Q

VN -79

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-14 cont'd

VENDOR REVIEW FORM

Vendor Number

Infant Cereal: (At Least one type of cereal must be rice) 1.' Are there at least 12 boxes of 8 oz. size of inlant cereal in stock? If no. how many boxes?_ __

2. Is rice cereal 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 within current date limit? If no, how many were not?_ _

Brand and Price of Infant Cereals: Beechnut Gerber Heinz

R;ce (Highest Price) $ _ _ _. _ _
s _____
s

Other (Highest Price)

NIS

$ _ _ _ __

$ _ _ _ __

$

Page 3 of4

Yes

No

a a

a

Q

a a

a a

a a

Comments on Infant Cereal: ________________________________________,

(Minimum of 32 cen of contracted soybase, 138 cans of mllkbase and 16 cans of LactoFree Formula) Are there 138 cans of 13 oz. concentrate milk based contracted formula with Iron in stock? If no, how many? Are there 32 cans of 13 oz. concentrate soy based contracted formula with Iron in stock? If no, how many?_ _ Are there 16 cans of 13 oz. concentrate LactoFree contracted formula with Iron in stock? If no, how many?_ _ Is formula within current date limit? If no, how many cans were not?_ _ Was price marked on cans or on shelf?

No

a

Q

Q

Q

Q

Q

Q

Q

a

Q

Milk: (Minimum of 20 gals. wnole milk, 2%, 1% & skim milk of the leest expensive brand)

1. Are there at least 20 gals. of milk in stock? If no, how many?__

NIS _ _

2. Was price marked on milk or posted on the dairy case?

3. Was milk within current date fimit? If no, how many were not? _ _

Lowest Price: $

and

Brand of Milk

Comments on Milk:

Cheese

1. 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 shelf/dairy case?

4. Was cheese within date fimit? If no, how many were not?_ _

Highest Prices of Cheese: American $ _ _ _ NIS _ _ Colby $_ _ _ NIS _ _ Cheddar $_ _ __ NIS

Monterey Jack$

NIS_ _ Mozzarella $ _ _ _ NIS _ _

Yes

No

a a

a a

Q

Q

Yes

No

Q

Q

Q

Q

Q

Q

Q

Q

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. Was price marked on eggs or posted on the dairy case? 3. Were eggs within date fimit? If no, how many were not?--

Lowe~ Price: $

and (Grade ALarge)

Nl$ _ _

Brand of eggs

Yes

No

Q

Q

Q

Q

Q

Q

CommentsonEgg~----------------------------------~------------;

Form 3774 (Rev. 7-96)

Routing: White - State WIC Office Yellow - Local Agerq Pink - Vendor

VN- 80

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-14 cont'd

VENDOR REVIEW FORM
Vendor Number___ _ _ _ _ _ Page 4 of 4

B. ParticipanWendor Observation (Not applicable for pre-approval) 1. Were any WIC vouchers on hand in the store? If Yes. were all voucher amounts filled in? - - -
If the VOUCher amount Is not filled in, ust the voucher number(s) in the comments section 2. Observed WIC participant making a purchase? If Yes, were appropriate procedures followed? _ _
Explain inappropriate procedures:

Yes No NA

0

0

0

0

0

0

Comments

..

C. General Questions/Observations
1. 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 observed? 4. Is there a need for additional training at this time? 5. Are all price columns for fOOds not in store marked N.I.S. (Not in Store). This answer must be yes.

Yes

No

0

0

0

0

0

0

0

0

0

0

To the best of his/her knowledge, the Retail Vendor Representative hereby agrees a~::! ~ovenants 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/agreement or within the contract period. The results of this monitoring visit have been discussed with nie and I understand the violations (if applicable) that were found and the food prices listed above are correct.

Signature of Vendor Representative

Date:-----------

Print Name of Vendor Representative
I have discussed aU findings, any violations and training needs (if applicable) with the appropriate vendor representative.

Signature of WIC Representalive

Date:------------

Prinl Name of WIC Representative Dislrict _ _ _ _ _ _ _ _ _ _ _ Unit _ _ _ _ _ _ _ _ __
Vendor Representative C o m m e n t s = - - - - - - - - - - - - - - - - - - - - - - - -

WIC Representative C o m m e n t s : - - . , . . . . - , - - - - - - - - - - - - - - - - - - - - - -

Form 3n4 (Rev. 796)

Routing: White - State Wte Office Yellow - Local Agency Pink Vendor
VN- 81

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-15

VENDOR REVIEW FORM INSTRUCTIONS

VENDOR NUMBER

Enter the number assigned to the vendor.

DISTRICT/UNIT

Enter the District/Unit number.

DATE OF VISIT

Enter the date you visited the vendor.

VENDOR NAME

Enter the name of the vendor.

STORE OWNER

Enter the name of the owner.

STORE MANAGER

Enter the name of the manager in charge.

STREET ADDRESS

Enter the complete street address ofthe vendor.

CITY

Enter the city in which the vendor is located.

COUNTY

Enter the county in which the vendor is located.

ZIP CODE

Enter the zip code of the vendor's address.

REVIEW TYPE

Check the appropriate box to indicate what type of visit you are

conducting.

Yendor SelfReview (vendotsubmitSSWtlh Ap"]ieatioitFor '

0



,.

Jt,.,...,...... ,

............. ,.,,,,.,... .

'c<<

Certificatiotilistirig foo(i itm ptic~s).

Pl'eiA.pproy~(,:t:Y~sit <:@Q..t~Pt~~~~~PX~',~lt ~q~~! 1'2.'9.1

~!~~iA~~~~i~~!~:i~~~.~~t~11ii~R~\!l~i~~~

~()A;;~g~hable ~~~l;fisa.t;~~,~f:}!i!~ Xi~~!);

t!IIAillll!

liowmg ~uw. rnYnt9rt ~~ru~ 9:f.X~!i49t ~~f.vf!s~~.::ef

food i.f~ihs):

f!:olloW~Upyisit(\V}Cf.~ptesent~tiv~.~:~~~t:~!t~~~~~tt

st()restha.t have. receivect. ~a,nc~i<his):.

", "" ,

~.



,,,,,;: ' 'h '-'VW '

VN- 82

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-15 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. If?t:l,;l,e
~'~~if()~:i~~nt?~:ll.lY:i~ ~~?.r~~ pJJ.ec!<:.tge.'~~':tP2*"~~p~9~f~ !IJ:~f ~efooq!f~fi).W~
I>Tot'mstr~

Example: _Yes __K_No

Are there at least 30 boxes of 9 oz. to 20 oz. WIC cereal in

stock? If no, how many? _Q_

Are fhere atleast8bags ():fJ6 &?:'J~ize peas!bearis in: st{)Ck'?

if;fi9i~~w il'itirif?dsE1ls~i$. ~~i



2. Check prices on all WIC approved food items to make sure the prices are marked on the items, on the vendor's shelves, or on the dairy cases. Check the appropriate box "Yes" or "No" on the form. If "No" is checked, please explain in the comment .section of each individual food category.

Example: _Yes __K_No

Was price marked on cereal or shelf? If no, explain: Prices were not marked on three boxes of 9 oz. Cheerios.

3. Check all WIC approved food items for acceptable expiration dates (cuirentgi;it~ l@lit)~ Check the appropriate box "Yes" or "No". If"No" is checked, explain what food item has expired, how many, and the date of expiration.

Example: _Yes__K_No

Was cereal within cl.lfientdate limit?
If no, how many were not? _L

Comments on Cereal: Two boxes ofK.ix were three weeks past the expiration date ofMarch. 1996.

4,

g~s9fq. ~ ~e~ ~t>CiQ~g~.Y~!lg()r 1le!f!!~~l11.gp~~S,f:otJoo~ 't!l~tt.~~t the rni!'i~~l

py~~tfY'r~tJ.uiiemen,ts~

VN -83

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-15 cont'd

VENDOR REVIEW FORM INSTRUCTIONS

Check the WIC vouchers on hand in the vendor's cash register(s). If all procedures were properly followed, check "Yes". If you notice a procedure that was not properly followed, check "No" and explain in the space provided in the,:f:j{p!fri liiapP.t.?pfi.ate')?r()eCi~s

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. Ifyou were not able to observe a participant while visiting a vendor, indicate that there were not any participants tS~ observe.
C. General Questions/Observations
1. Check the store's appearance for unremoved trash, dirt on the floor or shelves, evidence of vermin, 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 the WIC Representative Comment Section.
2. Is store open for business at least 8 hours per day, 6 days per week? Check "Yes" or "No". If"No" 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-84

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-15 cont'd

VENDOR REVIEW FORM INSTRUCTIONS

D. Signatures and Vendor Comments

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 fmdings and any violations.

WIC Representative Date:

The date of the WIC Representative's signature.

Signature ofVendor Representative:

The owner or manager should sign the form in the space provided. If they are not available, obtain the signature of the person in charge.

Venaor,Represeii~tiv'e:~Qo:nllnents:

.'. .......

. --:-'

-.... ...--...-

. .. ..-:-

thi$ The ven(ior reph~$eh~tive shqJ!ld plac:e ~ycorhl:nerit$ in $j)1.l(;e.
A~diti<5#~ p~~{~h6il~(i p~a#a6he~ if~~t~~.

VN -85

District/Unit/Clinic: - - - - County:---------Date of Incident:------Date Reported:------Follow-up Date
Person Filing Complaint Name: Address:
Phone: ( ) lncldeni/Complaint:
i
00 0\
Local Agency Resolution:
State WIC Ortlce Resolution/Comments:
.
Follow-up Report:
SWO Customer Service Coordinator: FORM 3772 Revised 2/95

GEORGIA DEPARTMENT OF flU MAN RESOURCES
WIC PROGRAM
INCIDENT/COMPLAINT FORM

Participation Information Name: Guardian: WIC I.D. Numher: D.O. B. Phone: ( )

Vendor Information Vendor/Vendor #: Employee Name:
Title: Phone: ( )

Type of Complaint: Participant [ J
Vendor [ I Local Agency/State WIC dffice Staff [ I
Local Agency/State WIC Information
Staff Name:
Phone: ( )

Signature:

;

Can Complaint be Closed at Local Agency?
Yes [ I No [I
Signature and Title: Date: Can Complaint be Closed at State WIC Office?
Yes [ I No I I
Signature and Title: Date:

Date: Routing: Original - Stall' WIC Office, Ydlow I>istrll'l WIC Office, Pink - WIC Clinic

~
~
<i
'"1:1
~
Q
~
~
00
i
"'!!'j ~ IC
-...)
~
J
(I)
~
~
.......
0\

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-17

Vendor ID: Vendor Name: Activity Date: District Unit: Vendor Type: County:

EXAMPLE VENDOR PROFILE ***Vendor Information*** 0482 Mom and Pop Mini-Mart 07/31196 51 2 116 ***Volume ofBusiness ***

Vouchers Paid (Current Month): $ Amount Paid (Current Month): Vouchers Paid- Fiscal Year To Date: $Amount Paid- Fiscal Year To Date: %Vouchers Exceed Fiscal Year 6 Month Average: # Vouchers Exceed 6 Month Average: %of Total DIU Vouchers: % of County Vouchers: # Vouchers Outside Vendor Area: $ Amount earned for vouchers received outside Vendor Area: % Vouchers Outside Vendor Area:

553 5,603 3,558 67,084
10.4 52 3.3 82.7 210 2,092 38.0

# Vouchers Paid Last 6 Months:

6

5

4

3

2

1

524

473

500

497

492

519

***Vendor Scores (07/96: Federal Fiscal Year 1996) ***

A B C1 C2 E1 E2 E3 F G H I M N 0 p Q TOT

95 98 8 0 100 0 0 1 1 0 8 0 38 0 3 20 392

X X

X

665 686 23 0 1125 0 0 12 12 0 60 0 266 0 3 120 2972

VN- 87

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-18

VENDOR APPLICATION BOOKLET COVER LETTER HEALTH DEPARTMENT LETTERHEAD

Dear Perspective WIC Vendor (Store Owner):

Per your request, enclosed is a WIC Vendor Application Booklet and a two 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, ifyou are purchasing a store that is currently a WIC approved store, we must receive the WIC vendor stamp from the owner before your application is processed. You must also submit a copy of the bill of sale.

Your compl~ted WIC Vendor Application must be returned to me at the address below no later than

4:00p.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 of WIC items, your

store's appearance, and your shelf prices. 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:

Enclosed in this package is a WIC Vendor Application Booklet and the two page application. VN -88

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-19

SANCTION SYSTEM

Georgia Deparunent of Human Resources \VIC Program
SANCTION SYSTEM

Store Name _ _ _ _ _ _ _ _ _ _ _ __

Vendor Representative _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

WIC Vendor Number_ _ _ _ _ _ _ _ __

District Unit _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

The following is a description of the sanction system and how it works:

A.

Category I - Two warnings for offense{s), third offense probation for six (6) months. fourth offense in c::ategory I, II, or m

disqualific::ation for six (6) months

I.

Stocking a WIC food item(s) outside ofmanufacrurer's not-to-exceed date{s).

2.

Prices not marked clearly on WIC food items or near WIC food items.

3.

Allowing WIC food items to exceed the quantity specified on the voucher {except for promotional items).

B.

Category II - Warning on first offense, second offense probation for eight (8) months, third offense in utegory I, II, or DI

disqu:tlification for eight (8) months

I.

Failure to repay overcharges based upon specific computerized reports.

2.

Failure to properly process vouchers at the store (this indudes failure to calculate (ring up) sales of WIC purchases; not

writing price on voucher before participant signs).

3.

Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or more

\VIC food items {types and/or brands). {Physical inventory must be viewed by a WIC representative at the time of visit.

Proofoforder of food items is not acceptable).

4.

Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.

S.

Allowing purebase of similar and/or non-similar food items in exchange for WIC vouchers (this includes allowing

substituti~ns f~r food items listed on WIC vouchers; substitution of one WIC food item for another; a!low4tg ,..

the purcliase ofWIC foods in unauthorized container sizes).

,..

6.

Failur: to remain open for business at least eight hours per day, six days per week.

7.

Failure to give a receipt for WIC purchases.

C.

Category ill - Warning on first offense, second offense probation for ten (10) months, third offense in category I, II, or ill

disqualification for ten (IO) months

I.

Discrimination.

2.

Issuing rain checks/lOU's.

3.

Contacting WIC participants for any reason regarding a WIC transaction.

4.

Requiring participant to pay cash to redeem WIC vouchers.

S.

Allowing the purchase of any formula other than the one specified on the front of the voucher.

D.

Category IV- Warning for first offense, second offense probation for twelve (12) months, third offense in category I, II, ill or V

disqualification for twelve (12) months, third offense in category IV or VI disqualification for three (3) years

I.

Overcharging on WIC vouchers (charging for foods not received or charging in excess ofshelf price or item cost for

food listed on the voucher) during a compliance purchase investigation.

Any Violation From Category V or VI That Occur At Any Time Will Result In Immediate Disqualification For The Period Specified In Category V or VI

E.

Category V- Immedi:tte disqualification for twelve {12) months for each violation

I.

Intentionally providing false information on vendor records.

F.

Category VI -Immediate disqualification for three (3) years (thirty-six months) for each violation

I.

Failure to provide vouchers or inventory records upon request.

2.

Transacting WIC vouchers outside of the WIC authorized ftxed store location.

3.

Failure to allow monitoring by WIC representatives.

4.

Accepting or purchasing vouchers from unauthorized stores or other unauthorized sources.

S.

Providing non-food items in exchange for WIC vouchers.

6.

Providing cash in exchange for WIC vouchers.

7.

Conviction of a felony related to store operations.

Vendor violations will be categorized by the severity and nature of the offense. Each category has a prescribed period of disqualification, probation, or warnings assessed. Warnings remain active an the vendor case file for a twelve {12) month period. A vendor found to be in
violation within the probationary period shall be disqualified for not less than the full probation:ary period or not more than three (3) mn.
Probationary periods are gr:anted by the State WIC Office and are notsubjeet to a fair hearing. Vendor will continue to operate his/her business daring the probationary period. Ifa vendor is disqu:alitied from Food Stamp Progr:am participation, the vendor shall be disqualified from WIC Progr:am participation for the same period of time, up to three (3) years. (Refer to Food Stamp Progr:am Federal Regulations 7CFR; Part 278), Disqualification will not exceed three (3) years. Disqualification from the WIC Progr:am may also result ia disqualification from the Food Stamp Progr:am.
As per Feder:al Regulation 246.12 {kX1), the Georgia WIC Progr:am has taken into account the severity and nature ofviolations ia establishing the Sanction System.
I have re:td and understand the Sanction System as acknowledged by my signature listed below: .

Owner/Manager

Date

Form 3796(Rev.7-96) Routing Copies:

Local Agency Authorized Representative Date

White-SWO Yellow- Local Agency

Pink- Vendor

VN -89

GA WIC PROCEDURES MANUAL FY '97
...
PHARMACY HANDBOOK
WIC

Attachment VN-20

Phannacy

Handbook

GEORGIA DEPARTMEN! OF HUMAN RESOURCES

VN-90

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

What is WIC? VVIC stands for Women, Infants, and Children. The VVIC Program is funded by the U.S. Department of ~ariculrure and is administered in Georgia by the Department of Human Resources through state, district and local health offices.
VVIC 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. \VIC gives children a chance to grow up healthy and lead active, productive lives. VVIC Program participants have been examined by health professionals who determine the need for sup- plemental foods and nutritional guidance. - The participants receive vouchers for special kinds of highly nutritional foods. These vouchers are redeemed by participating grocers or pharmacies (vendors) who have signed an agreement to follow all "WIC Program requirements.
The Application Process
Step 1-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 and pharmacy price list (see pages 13-15 for a copy of application) and rerum these forms to the Local \VIC 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 bill 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. The pharmacy must be free from any current

Food Stamp Program Sanctions.



4. The pharmacy appearance must be sanitary with no evidence of general lack of cleanliness. The State WIC Office will work with the Georgia Department of A:,crriculrure 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 limiffor human consumption.
7. "WIC pharmacies are only allowed to sell special formula. Pharmacies shall not sell food items such as milk, cheese, eggs, juice, cereal, peas/beans, peanut butter, tuna, carrots, and infant cereal.
8. The ''WIC'' acronym or logo cannot be utilized by a pharmacy with the exception of documents distributed to the pharmacy by the Georgia "WIC Program.
Applications are accepted each weekday and should be returned to the Local Agency to be processed along with the pharmacy price list that is completed by the pharmacy. The application process takes 45 working days for completion. Therefore, a pharmacy that wishes to receive approval regarding VVIC pharmacy authorization must submit a completed WIC application form 45 days prior to the pharmacy opening or change of ownership.
If the pharmacy's prices charged for WIC approved formula meets the state pricing criteria standards, the State WIC Office will forward the WIC authorization stamp to the Local Agency with a copy of tfle application and the pharmacy vendor registration form. The Local Agency will give the appropriate training, have the owner/manager of the pharmacy sign the Pharmacy A:,crreement, and issue the WIC authorized

VN -91

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

stamp. D.o not acept 'WIC vouch~rs prior to train- must be requested within fifteen (15) days of receipt of

ing and signing the "'WIC Pharmacy A::,OTeement

the denial notification. The appeal should be submit-

(contract).

ted to the address below and not the Local \VIC

If a pharmacy 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 deficiencies within 35 working days of denial. If a pharmacy does not correct the deficiencies within 35 working days of denial, a new application must be re-

Agency. State 'WIC Office
Two Peachtree St., Nw, 8th Floor Atlanta, Georgia 30303 (404) 657-2900 or
'WIC Hotline: 1-800-228-9173

submitted to the Local Agency.

Step 3-Training and Signing the

The WIC Food (Formula) Voucher

Agreement
Once a pharmacy has been approved, the pharmacy will be trained by the Local 'WIC Agency and a WIC pharmacy agreement will be signed by the pharmacy owner or pharmacy manager prior to issuance of the vendor stamp and the acceptance of 'WIC vouchers.
A 'WIC pharmacy 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 pharmacy 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

The voucher for \VIC foods is a check. and should be redeemed just as carefully. "When a voucher is properly redeemed, the pharmacy will receive credit for the amount of purchase by depositing it in his/her bank account. The pharmacy is responsible for any mistakes that cashiers make with 'WIC vouchers, so he/she must be sure that they know all 'WIC voucher redemption requirements. The State and Local 'WIC Offices can assist with cashier training as needed.
A 'WIC pharmacy must accept all valid \VIC 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 \VIC vouchers, computer generated, standard manual, and blank manual.

Computer generated voucher: All information on this voucher is computer printed.

32845232

--na.t~OOLY-110_,_
H80;~raCKASE~Uk: ~ ' WUCICJl.COCE 03~ ,-t~JU:. 1-U&.,~:,~u.-ez CIIS WAf!
. -:.IOIUl~ U toa
atESC: .UP 10 1: L8
,.UJC: 1~UezCM.F~OzOMl~6 QlC"MI

YOUR BABY HEEDS SHOTS AT 2 MONTHS, 4 MONTHS, ~ISU:e~~

8 MONTHS, 15 MONTHS, & 5 YEARS

STA~

0 QE,~ VN -92

GA WIC PROCEDURES MANUAL FY '97 ::

Attachment VN-20 cont'd

PHAR.t\1ACY HANDBOOK
Standard manual voucher: Manual vouchers are processed in the same manner as computer generated vouchers. The standard manual voucher has the name, I.D. number and dates written or typed by the staff at the clinic.

11 74789531 7t789531 6

!'RAH
GEORGIA WJC PROGRAM
DPARTMEHT OF HUMAN RESOURCES

...:lUOERNO.
7 4 789531~~ rtt~iof

KD&r

VC.'ft7

00 0b3 00~

Blank Manual Vouchers: The blank manual voucher has the name, I.D. num-
ber, 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.

OJ Exajp'ef
I. X
D W
2. ~ [1]
D !241

Correct Incorrect Correct Incorrect

X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alteration on the voucher(s).

VOUCHER NO.
~9459203

VENDOR MUST DEPOSIT BY

FOR nSe I'T'EMS I~ ON..Y -NO SUBSTn'1.1'nONS

;.:1,~oo~:!:.P".~CICAG~~ec~ooe~====..;VOI.JaieR coce
LI U U '-~ -n--~--------'IICEREAL

OZ ln13nt
ozMJt

D r-j.M-ce--,...0-, -'6 oz c.ns



12 OZ Cans/Fnn.

jCHEESE
IEGGS

.lib$ I Coz

: J U < OGatslPFoUwddered
12 oz Cans Evap.

j I j PEAS/BEANS

lb Cried

'h Gal uetose F-

ITJ :.,- Type-

I I I PE.\JT B\1l"'reR

~ to 18 oz CARROTS

jTUNA

I I 6 1/8 oz Cans

ats 1..ao:1ose Free 11b PrMealed Pltg ( -----

v t J I I J ) _______ ~~~~~ , UTHnqqt.5'i2Qj111 r:Q!;10QQQ?81: 00 0!;j QQn __.:_

-

VN -93

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

Prqcessing WIC 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. After the vouchers are accepted, they must be stamped with this number in preparation for a bank deposit. The pharmacy should inform his/her bank before or at the rime of his/her first deposit that the vouchers can be delivered through the Federal Reserve System to the Nations Bank 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 authorized 'WIC vendor stamp appears on the face of the voucher.
3. A total amow1t 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 used the voucher in your store after the "First Day to Use" and or 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. Endorsement(s) does appear at the bottom left-corner (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 computer-generated vouchers. 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 WIC Customer
"When food is purchased with a 'WIC voucher, the cashier must do the following:
I. Check the customer~ 'WIC identification card for the proper WIC ID 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 ID card.
2. For manual vouchers, 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 cannot be u.Sed before the "FirSt Day to Use" nor after

the "Last Day to Use" dates. 4. Ring up the shelf price or price on item(s) ofWIC
food(s) for each voucher. Make sure that 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 his/her name, the 'WIC customer must make his/her 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 his/her 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.
'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 ma.ximum amount allowed on the voucher(s).) However, 'WIC purchases are exempt from Sales Tax.
Separate check-out lines for 'WIC participants in pharmacies are prohibited. Signs such as "'WIC vouchers not allowed in this line" or "No checks, No 'WIC" cannot be displayed since they are considered discriminatory. However, 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.
If a manager is called to approve a 'WIC voucher transaction, it is imperative that the customer is not identified as a 'WIC participant over the public address system. Every effort must be made to protect the confidentiality of the participant/proxy, and discussion of the transaction should be kept at a conversational level.
Provisions I.J. and LK. of the Vendor Agreement
state that 'WIC participants must be accorded "the same courtesy given to other store customers," and store personnel must "keep all information confidential on 'WIC participants." 'WIC customers may not receive change from WIC

VN -94

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

voucher purchases or credit in exchange for \VIC vouchers.
\VIC customers may not be contacted regarding any payment problems with \VIC vouchers. Contact the Local \VIC clinic if a need to contact a \VIC customer should arise. (See page 19 for a copy of the Incident/Complaint form.)
Food purchased with a \VIC voucher cannot be returned for a cash refund. (Cashiers should write "\VIC" on receipts given for food purchased with \VIC vouchers).
The customer may not use a \VIC voucher to purchase any item not listed on the \VIC voucher.
The \VIC customer must never be required to pay any additional cash for items purchased with \VIC vouchers. A \VIC voucher cannot be redeemed for more than the maximum purchase price listed on the front of each voucher.
Voucher Payment Policy
Any \VIC 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 \VIC Program with the Rerum Voucher Payment Log to be processed for payment. The State \VIC Office shall only reimburse pharmacies for vouchers at a rate of the vendors shelf price(s) up to, but not over, the "not to exceed" maximum amount listed on the front of each voucher. In order for vouchers to be paid, the State \VIC Office must obtain the vendor's Federal Employer Identifier (FEI) number or the owners Social Security Number (SSN) if the FEI number is unavailable.
Any WIC voucher returned by the bank to the pharmacy because of a stale date will not be paid.
Voucher Payment Procedure
If a voucher has been returned to the \VIC pharmacy 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 rerum voucher payment log (form number

3760) must be completed and sene with the original \VIC voucher(s) to the State 'WIC.Office.
The pharmacy 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 pharmacy.
If a voucher(s) is denied payment, a copy of the form will be returned to the pharmacy with an explanation for denial. Also, the original voucher will accompany the form. No payment will exceed the voucher "not to exceed" maximum.
Pavment on vouchers received without the form wiil be delayed.
Compliance Performance
The performance of every pharmacy is reviewed in at least one of the following ways:
Monitoring
All 'WIC pharmacies will be reviewed through onsite 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. (See page 9 for a copy of the Review Form.) 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 \VIC Office may conduct record audits on any pharmacy at any time. During an audit, the pharmacy must supply the \VIC representative with documentation of pertinent records upon request.
Pharmacies must retain copies of all invoices relating to the purchase of \VIC food items for a period of two (2) years.
Compliance
lnvestigationNendor Profile
Compliance investigations shall be conducted in authorized 'WIC vendor stores or pharmacies. ' Pharmacies identified for investigation 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 \VIC Program for potentially violating program regulations. Non-potential high risk vendors or pharmacies will be randomly selected for investigation. A minimum of twenty (20)

VN -95

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

percent of"WIC vendors will be investigated each fiscalyear. Investigators shall shop with \VIC vouchers co determine whether a score is complying with \VIC Program requirements.
Any vendor or pharmacy identified as being potentially high risk will be investigated by the Scace \VIC Office. If the vendor is found co be in violation of program policies and regulations through an investigation, he/she will be assessed sanctions for violations occurring in each investigative visit or will.be disqualified according co the points assigned. Notification of investigation results will be given ac the close of the district investigations.
Pharmacies not involved in a current investigation will be notified of ocher administrative sanction assessments at the time they are assigned.
Pharmacy Agreement Renewal
By federal regulations, the state does not have to renew agreements with \VIC pharmacies. Any \VIC pharmacy who has not signed a pharmacy agreement within 30 days after the expiration date will be terminated and may reapply by submitting a vendor application. In order for a \VIC pharmacy agreement to be renewed each year, the pharmacy muse meet requirement 1-8 under The Application Process.
Sanctions Disqualifications, and Terminations
Any VVIC pharmacy found to be in violation of program policy and/or regulations will be assessed a sanction consistent with the severity and nature of the violation. Each violation of program policy and/or regulations has a sec sanction and a specific time period during which the sanction will remain on the vendor record. In addition, a vendor shall be disqualified from \VIC Program participation if disqualified from Food Stamp Program participation.
All sanctions earned are retained on the vendor file for a period of one year. Sanctions will "roll off" one year from date of receipt.
Disqualifications
All sanctions earned are retained on the pharmacy file for a period of one (I) year. Sanctions will "rolloff" one (I) year from the date of receipt. The period of disqualification is determined by the severity and nature of the violation, the number of violations, probations, and past disqualifications. Any pharmacy disqualified from WIC Program participation may be disqualified from the Food Stamp Program. (See
page 5 Compliance Investigation/Vendor Profile.)

Probation Period and Hardship Cases
If disqualifying a pharmacy causes hardship to WIC participants, the pharmacy shall be granted a probationary period. A probationary period can be granted only once per authorized \VIC pharmacy. A hardship case is granted only when the nearest authorized WIC vendor is I0 miles or more away from the nearest \VIC clinic. If a violation occurs within the probationary period, the pharmacy shall be disqualified for the full disqualification period.
Sanction System The following is a description of the sanction system
and how it works: A. Category I -Two warnings for offense(s), third
offense probation for six (6) months, fourth
offense in category I, II, or m disqualification for
six (6) months 1. Stocking a \VIC food item(s) outside of manufac-
turer~ not-to-exceed dace(s). 2. Prices not marked clearly on WIC food items or
near \VIC food items. 3. Allowing \VIC food items to exceed the quantity
specified on the voucher. (Except for promotional items) B. Category IT- Warning on first offense, second offense probation for eight (8) months, third
m offense in category I, II, or disqualification for
eight (8) months 1. Failure to repay overcharges based upon specific
computerized reports.
2. Failure to properly process vouchers at the store (this includes fuilure to calculate [ring up] sales of "WIC purchases; not writing price on voucher before participant signs).
3. Failure to StoCk the required inventory of contracted formula or fuilure to StoCk the required inventory of two or more WIC food items (types and/or brands). (Physical inventOry must be viewed by a WIC representative at the time ofvisit. Proof of order of food items is not acceptable).
4. Refusing to accept valid "WIC vouchers from participants in exchange for \VIC food items.
5. Allowing purchase ofsimilar and/or non-similar food items in exchange for 'WIC vouchers (this includes allowing substitutions for food items listed on "WIC vouchers; substitution ofone "WIC food item for another; allowing the purchase ofWIC foods in unauthorized container sizes).
6. Failure to rei:nain open for.business atleast eight hours per day, six days per week.
7. Failure to give a receipt for "WIC purchases.

VN-96

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

C. Category ill -Warning on first offense, second offense probation for ten (10) months, third
m offense in category I, II, or disqualification for
ten (10) months 1. Discrimination
2. Issuing rain checks/lOU's.
3. Contacting "WWC participants for any reasons regarding a "WWC transaction.
4. Requiring participant to pay cash to redeem \VIC vouchers.
5. Allowing the purchase of any formula other than the one specified on the front of the voucher.
D. Category IV- Warning for first offense, second offense probation for twelve (12) months, third
offense in category I, II, m or v disqualification
for twelve (12) months, third offense in category IV or VI disqualification for three (3) years
1. Overcharging on "WWC vouchers (charging for
foods not received or charging in excess ofshelf
price or item cost for food listed on the voucher) during a compliance purchase investigation.
Any Violation From Category V or VI That Occur At
Any Tune Will Result In Immediate Disqualification For The Period Specified In Category V or VI

od shall he disq!talffied for not less than the full probatioruu:y period or not more than three (3) years. Probationary periods are granted by the State 'WIC Office and are not subject to a fair hearing. Vendor will continue to operate his/her business during the probationary period. Ifa vendor is disqualified from Food Stamp 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 Stamp Program Federal Regulations 7CFR; Part 278). Disqualification will not exceed three (3) years. Disqualification from the \VIC Program may also result in disqualification from the Food Stamp Program.
As per Federal Regulation 246.12 (k)(l), the Georgia \VIC Program has taken into account the severity and nature ofviolations in establishing the Sanction System.
Example 1:

1st

2nd

Warning Warning

Letter

Letter

3rd Letter. Fmal letter 8 month 8 months DisProbation qualification

E. Category V - Immediate disqualification for twelve (12) months for each violation
I. Intt:ntionally providing false information on vendor records.
E Category VI - Immediate disqualification for three (3) years (thirty-six months) for each violation 1. Failure to provide vouchers or inventory records upon request. 2. Transacting "WWC vouchers outside of the WIC authorized fixed store location. 3. Failure to allow monitoring by "WWC representatives. 4. Accepting or purchasing vouchers from unauthorized stores or other unauthorized sources. 5. Providing non-food items in exchange for "WWC vouchers. 6. Providing cash in exchange for "WWC vouchers. 7. Conviction of a felony related to store operations.

Category Category Category

I Offense I Offense IT Offense

#!

#2

#3

Category li Offenses
#2 and #5

Category I Offense
#3
(Violation occurring
during probation)

Category
m
Offense
#2

Vendor violations will be categorized by the severity and nature of the offense. Each category has a presaibed period ofdisqualification, probation, or warnings assessed. Warnings remain active on the vendor
case file for a twdve (12) month period. A vendor
found to be in violation within the probation:uy peri-

VN -97

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

~ple2:

1st Warning Letter
.,
..
...

2ndWaming Letter 8 month Probation

3rd Letter Inunediate Disqualification for three (3) years

Category I Offense #2

Category IT Offense #3

Category VI Offense #4

Category IT Offenses #1 and #4

pharmacy agreement thirty (30) days after the second notification. Pharmacies scheduled for termination will receive an opporrunity to sign a contract addendum, stating that the pharmacy agrees to lower his/her prices on specified WIC items, to avoid termination. (fhe policy, procedures and specific addendum stipulations are detailed in the current Georgia WIC Procedures Manual in the VN section under Terminations/ Disqualifications.)
Changing Pharmacy location
When a pharmacy moves to a new location but is still under the same management, the Local WIC Agency must be notified of the address change immediately.

Category ill Offense #1
Terminations
1. If a pharmacy 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 pharmacy decides to sell a business, the owner must: a. Notify the Local WIC Agency of the transaction. b. Return Vendor Stamp(s) to the Local WIC Agency immediately.

Where to Get More Information
Local WIC offices can offer help to pharmacies if questions or problems arise. Most WIC offices can be contacted through the county Health Departtnent. The State WIC Office in Atlanta can also provide assistance. To contact the State WIC Office, phone or write to this address (please have your WIC vendor number available when calling or listed when writing):
Georgia Department of Human Resources State WIC Office
Two Peachtree St., N.W. 8th floor
Atlanta, Georgia 30303 (404) 657-2900
or call the WIC Hotline 1-800-228-9173

Hearing/Appeal Procedures
Pharmacies are entitled to a fair hearing upon disqualification from the WIC Program. Any pharmacy 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.

Standards for participation in the program are the same for everyone, regardless ofrace, colar, national origin, age, sex, handicap, religious or political belief

Contact/Agreement Non-Renewal Policy
Shelf prices (on \VIC-approved foods) of the pharmacy 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 of similar size and/or type. Continued overpricing after two (2) written notifications from the State WIC Office, shall result in termination of the

VN -98

GA WIC PROCEDURES MANUAL FY '97
...

Attachment VN-20 cont'd

PHARMACY HANDBOOK

Georgia Oepartrnent of Human Resources
Division of Public Health WIC Program
VENDOR REVIEW FORM

Vendor Number

Page 1 of4

District

Unit

Date of Visit

I

I

Vendor Name

Store Owner

Street Address

City

Review Type
o Vendor Self Review (attach to Vendor Application) o Pre-Approval Visit (Non-perishable Food Review) 0

0 New Vendor (not applicable as yearly visit)

0

Yearly Visit Follow-Up Visit

Store Manager County

I Zip Code

0 Minimum Inventory Waiver Granted 0 Regular Minimum Inventory Required

Note: Physical Inventory must be viewed by WIC representative at the time of visit Proof of order of food items shall not be accepted.

A

Minimum Inventory Requirements

Juice:
1. Are there at least 24 cans of 46 oz. size juice in stock? If no, how many cans? _ _

2. Are there at least 12 cans of 12 oz. size frozen juice in stock? If no, how many cans?_ _

3. Are there 2 types each of frozen and canned juice? If no, how many? Cans_ _

Frozen _ _

4. Was price marl<ed on juice or posted on the sheiYclairy case?_ _

5. Was juice within date limit? If no, how many were not? Cans _ _

Frozen _ _

Yes

No

0

0

0

0

0

0

0

0

0

0

Apple
Grape: White Grape: Orange: Grapefruit Other: Cole
Juicy Juice

Brand Name Flav-<Hite Kroger Juicy Juice Lucky Leaf Saneca (Red Label) Shur Fine Staff Thrifty Maid WhiteHouse Juicy Juice Welch's 100% Welch's Seneca Least expensive only Least expensive only Pine-Orange-Banana Pineapple-Orange Pineapple-Passion-Banana Pineapple-Orange-Guava Mandarin Tangerine Mountain Cherry Orchard Peach Country Raspberry Tropicai Fruit Pineapple-Grapefruit Cherry Tropicai Punch

NIS

Prices: 46 oz. NIS Prices: 12 oz. Frozen

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

s

$

$

$

s

$

$

$

$

$

$

$

$

$

$

$

s

$

$

$

$

$

$

$

$

$

s

$

$

$

$.

Strawberrv

$

$

Aoole-Graoe

$

$

Oranoe Punch

$

$

Berry

$

$

Comments on Juice:

Form 3774 (Rev. 7-96)

Routing: White - State W.c Office Yellow - Locai Agency Pink -Vendor
VN -99

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

' Cereals: (At least two types in 12 oz. sizes)

Vendor Number

1. Are there at least 30 boxes of 9 oz. to 20 oz. siza of cereal in stock? 11 no, how many?__

2. Are there at least 4 types of WIC cereal in stcek? If no, how many? _ _

3. Are there at least 2 iypes of 12 oz. size boxes of cereal in stock? If no, how many? _ _

4. Was price marked on cereal or on shell?

5. Was cereal wiltlin date limit? If no, how many were not? _ _

NJS

Oz. Size

Cheerios

ComChex

Rice Chex

WheatChex

Countty Com Flakes

Crispy Critters

Kix

Kellogg's Com Flakes

Special K

Product 19

Total. Com Flakes

Harvest Instant Oatmeal (Regular)

Jim Oandv Quick Grits (Iron Fortified)

Minute 3 Brand Instant Oatmeal Plus Oat Bran (ReQUiar)

Nabisco Quick Cream of Wheat (Regular)

Quaker Instant Grits (Original)

Quaker Instant Oatmeal (ReQular)

Kellooa's Complete Bran Blakes

Quaker Sun Coumrv Quick Oats (Regular Flavor)

Quaker Oats Crunchy Com Bran

Ralston:

Optima 100 Whole Wheat Flakes Enriched Bran Flakes

Nutty Nuooets

Instant Oatmeal (Regular Flavor)

CriSPvRice

Com Flakes

Tasteeo/Toasted Oats

Crispy. Com Puff

Ralsten Store Brands Allowed: Krooer. Kountrv Fresh. IGA. Red & White. Flavorite or Nature's Best

Comments on Cereal:

Peas/Beans
1. Are there at least a bags of 16 oz. size peas/beans in stock? If no, how many?_ _
2. Are there at least two types of peas/beans? If no, how many'L_
3. Was price marked on peas/beans, or on shelf?

Brand

Type

NIS_ _

Comments on Peas/Beans

Page 2 of4

Yes

No

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Highest Prices $ $ $ $ $ $ $ $ $ $
s
$ $ $ $ $ $ $ $ $
s s
$ $
s
$ $ $

Yes

No

Q

Q

Q

Q

Q

Q

Highest Prices

$

$

Peanut Butter: (No peanut butter/jelly combinations or Honey Spreads) 1. Are there at least B jars of 18 oz. peanut butter in stock? If no, how many2_ _ 2. Are there at least two brands of peanut butter? If no, how many2_ _
3. Was price marked on peanut butter, or on shelf?

Highest Price S

and

Comments on Peanut Butter:

NIS-Brand of Peanut Butter

Form 3774 (Rev. 7-96)

Routing: White - State Wic Office Yellow - Local Agency Pink - Vendor

VN -100

Yes

No

Q

Q

Q

Q

Q

Q

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

Vendor Number

Infant Cereal: (At Least one type of cereal must be rice) 1. Are there at least 12 boxes of 8 oz. size of infant cereal in stock? If no, how many boxes?_- -
2. Is rice cereal in stock? 3. Is there one other type, other than rice, in stock? 4. Was price marked on cereal or on shelf?
s. Was cereal within current date limit? If no, how many were not?_ _

Brand and Price of Infant Cereals: Beechnut
Gerber

Rice (Highest Price) $ _ _ _ _ __ $ _ _ _ __

Other (Highest Price)

NIS

$ _ _ _ __

$ _ _ _ __

Heinz

$

$

Page3 of4

Yes

No

0

0

0

0

0

0

0

0

0

0

Comments on Infant Cereal: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _- l

.-nnn1m~ (Minimum of 32 can contracted soybase, 138 cans of milkbase and 16 cans of .....c,crn:a Are there 138 cans of 13 oz. concentrate milk based contracted fo1T11ula with Iron in stock? If no, how many?
Are there 32 cans of 13 oz. concentrate soy based contracted foiT11ula with Iron in stock? If no, how many?._ _ Are there 16 cans of 13 oz. concentrate L.actoFree contracted fo1T11ula with Iron in stock? If no, how many?_ _
Is fo1T11ula within current date limit? If no, how many cans were not?_ _ Was price marked on cans or on shelf?

Yes

No

0

0

0

0

0

0

0

0

Milk: (Minimum of 20 gals. whole milk, 2'l'o, 1% & skim milk of the least expensive brand)

1. Are there at least 20 gals. of milk in stock? If no, how many?__

NIS _ _

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:

and

Brand of Milk

Comments on Milk:

Cheese 1. 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 sheiYdairy case?

4. Was cheese within date limit? If no, how many were not?_ _

Highest Prices of Cheese: American $___ NIS __ Colby $

NIS _ _ Cheddar

NIS

Monterey Jack$

NIS _ _ Mozzarella S ___ NIS _ _

Yes

No

0

0

0

0

0

0

Yes

No

0

0

0

0

0

0

0

0

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. Was price marl<ed on eggs or posted on the dairy case? 3. Were eggs within date limit? If no, how many were not?_ _

NIS _ _

Yes

No'

0

0

0

0

0

0

Lowest Price: S

and (Grade A large)

Brand of eggs

CommentsonEggs: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~

Form 3n4 (Rev. 796)

Routing: White State Wrc Office Yellow Local Agency Pink - Vendor
VN- 101

GA WIC PROCEDURES MANUAL FY '97
...

Attachment VN-20 cont'd

PHARMACY HANDBOOK

Vendor Numbe"--------Page 4 of 4

B. PartlcipanWendor Observation (Not applicable for pre-approval) 1. Were any WIC vouchers on hand in lhe store? If Yes, were all voucher amounts filled in? - -
If !he voucher amount is not filled in, fist !he voucher number(s) in !he comments section 2. Observed WIC participant making a purchase? If Yes, were appropriate procedures followed? _ _
Explain inappropriate procedures:

Yes No NA 0 0 0

0

0

0

Comments
C. General Questions/Observations 1. Does !he store need to be referred to !he Georgia Department of Agriculture for inspection? 2. Is store open for business at least 8 hours a day, 6 days a week? 3. Has disaimination been reported or observed? 4. Is !here a need tor additional training at !his time? 5. Are all price columns for foods not in store marl<ed N.I.S. (Not in Store). This answer must be yes.

Yes

No

0

0

0

0

0

0

0

0

0

0

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/agreement or within the contract period. The results of this monitoring visit have been discussed with me and I understand the violations {if applicable) that were found and the food prices listed above are correct.

Signature of Vendor Representative

Date: _ _ _ _ _ _ _ _ _ __

Print Name of Vendor Represenlalive

I have discussed all findings, any violations and training needs {if applicable) with the appropriate vendor representative.

Signature of WlC Representative

Date: _ _ _ _ _ _ _ _ _ __

Prlnl Name of WlC Representative D~~ct_ _ _ _ _ _ _ _ _ _ _ _ _ u~-----------
Vendor Representative Comments: _________________________

WIC Representative Comments: _________________________

Form m4 (Rev. 7-96)

Routing: White - Slate Wic Office Yellow - local Agency Pink - Vendor
VN -102

GA WIC PROCEDURES MANUAL FY '97
..

Attachment VN-20 cont'd

PHARMACY HANDBOOK

Georgia Department of Human Resources DIVISION OF PUBUC HEALTii
FOR WOMEN, INFANTS AND CHILDREN
WICPROGRAM APPLICATION FOR VENDOR CERTIFICATION

Area Code

Store Name

Telephone Number

(____)

Store Location

City

GA Zip Code

Mailing Address (If Different)

County

Store Owner

Store Manager

F.E.L Number

or Owner's Soc. Sec. Number

(Federal Employer Identifier)

TYPE OF STORE

HOURS OF BUSINESS

Q Chain

Sunday

Monday

Q Independent

Tuesday

Wednesday

Q Franchise

Thursday

Friday

Q Drug

Saturday

Square Footaee of Store (squar, foo'-'3C o(Grcocry S""" :llld Grcocry S~c Spoo:~ Average Annual Gross Sales $

Number ofCheck-out Counters

Estimated Total % of Food Sales

q;,

Food Stamp Authorization Number

(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 ofAgriculture to be a WIC vendor)

Business License Number

Sales Tax Number

Length of time business has operated at the present site

Date store will open/change of ownership date

Yes No

Q

Q

Q

Q

Do you sell beer, wine, or other alcoholic beverages? Has the business ever operated under another name? If yes. what was the name of the business?

Q

Q

Is this a change of ownership?

Q

Q

Does this store now participate in the Food Stamp Program?

Q

Q

Has this store ever applied for WIC? If yes. state when

Q

Q

Has this store ever received a warning, been suspended. disqualified, or had a penalty assessed against it by

WIC or Food Stamps? If yes. state when and explain

STATE WIC OFFICE USE ONLY

FoodPkg.#

Vendor Cost

Max

FoodPkg.#

Vendor Cost

Max

FoodPkg.#

Vendor Cost

Max

Arc store prices competitive with other stores in State?_ _ _Yes_No

Application:

Approved

Date

Vendor Number Assigned

Denied

Date

Processed by

Reason Denied

Price Approved

Denied _ _ _

Price Approved--- Denied _ _ _

Price Approved

Denied _____,

.

Form :J770 (ReT. 796)

Pagel ol:Z

VN- 103

GA WIC PROCEDURES MANUAL FY '97
...
PHARMACY HANDBOOK

Store Name Name of bank where WIC vouchers will be deposited DaiQ: products are received from Other WIC products are received from Do _YOU own or manage any other grocery store(s) I drug store(s)? Q Yes If yes, list name :rnd addresses of store(s)

0 No

Attachment VN-20 cont'd
I

To the best of my knowledge, all of the above answers are correct. I understand that, should my store be accepted as a WIC vendor, I will abide by WIC Program regulations and policies including, but not limited to the following:

I. Attend Vendor Education; 2. Train employees regarding WIC procedures: 3. Periodical monitoring and; 4. All items in the Vendor Agreement.

I UNDERSTAND THAT TinS IS ONLY A REQUEST FOR APPROVAL AS A WIC VENDOR AND DOES NOT CONSTITUTE APPROVAL TO PARTICIPATE IN TilE WIC PROGRAM. THEREFORE, I WILL NOT ACCEPT ANY WIC VOUCHERS UNTn. SUCH NOTICE OF APPROVAL HAS BEEN MADE, I HAVE A1TENDED VENDOR TRAINING, AND I HAVE BEEN ISSUED A WIC VENDOR STAMP.

Signature

Date

Title

This is an Equ:d Opponunity Progr:un. Persons who believe they ltlvc been discriminaled apinst bcc:ouse of=. color. national origin. sex. age, or handicap should
write immcdi=ly to Scc=y ofAgric:ulturc. Washington. D.C. 202SO.

YES NO

Q

Q

FOR LOCAL USE ONLY Is the state required minimum inventory ofWIC approved foods in the store during the Pre-Approval visit?

Comments:

Q

Q

Comments:

Have you provided the vendor with the Georgia WIC Application Packet?

I certify that I have visited this store and do I do aot recommend its approval for participation. If this application is not recommended for approval, please explain why:
. -

DIS1'RICT UNIT
Form 3170 (R.,.. 7-96)

LOCAL AGENCY WIC COORDINATOR OR DESIGNEE
VN -104

DATE

.

'

Page2of2

GA \VIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

ENFAMIL WITH IRON

PHAR.l\1ACY HANDBOOK
GEORGIA W. I .C. PROGRAM
PHARMACY PRICE LIST
Please fill in the prices for all formulas available in your pharmacy.

VN- 105

REV. 7/96

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK

G410f'9'.:J O.CI.artment of Human Resources Oi'ftSaOn 01 PubtC Healtft WICProgr.m
(SPECW. SUPPlEMENTAL FOOO PROCiRAM FOR WOMEN. INFANTS & CHILDREN)
PHARMACY AGREEMENT

Page 1 of 3

This Pharmacy/Provider Agreement is made by and between the Georgra Department of Human Resources. Division of Public HeaHh. Health District

----.Unit

(hereinafter referred to as the Local Agency) a n d - - - - - - - - - - - - - - - - - - - - - - - - - -

(hereinafter referred to as the Vendor) to provide a mechanism for the distribution of special suPPlemental formula to eligible W!C partiCIPants in the

county(iesl included in this Health District Jurisdiction. This agreement will become effective o n - - - - - - - - - - - - - - - - - - - - -
and will terminate on--------------WIG VENDOR NUMBER

The undersigned represents the Vendor as the sole propr~etor or the The undersigned represents the Local Agency and has the authority to -pharmacy manager to contract for and on behalf of the Vendor identified contract for and on behalf of said agency.
be/ow. (Signature MUST be of owner or pharmacy manager.)

5o;na1ure o1 Ptwmacv 0wne< "' Manage.

O..te

fPnntl Name of Prwmaey Owner or Manager

""""' ollleoclo< (I'Ntmacyl
Mawng .AdQress Street P.O. eo.

Street Location ol Pharmacy - Slteer Aoaress

Cdr

SUte

z., Cede

Tetecnone-

~of Pharmacy Ornet (tl different from aDOYel

Maotong-ress

Cdr

SUte

z., Cede

S.;nature ot 1.o:.at ~ Autnonzec Reoresencar....e (Pntltl Name of l..oc:.aJ AQercy Auii'"Cinzed Reor~tn~e

Name ol """" Aqeney

Ma!Ung AOdrns Srreet P.O. Sox

Cdr

SUte

z.,c-

TetecnoneNumoe<

Esnmaled "- ot Fornua. Sales
- Soua<e Foo1a9e or s"""
FeaetoiE_ _ _ _

"-090 ........ Gtoss Sales
ol Cash Ae9slers
"' - -
Socal Seamty-

Notary Pubtic Signature and Seal

Date

Notary PubUc's Commission Expires

PURPOSE:

This Agreement is for the purpose of Providing a mechanism for the distribtution of certain listed formula to eligible ~Jarticipants and the redemption of n~egotiable food instruments for the purchase of said formula items. The Vendor is retained solely for the purpose
set forth herein and shall not be considered as an employee or agent of the Department

THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT.

COMMERCW.J6USlNESS SANK ACCOUNT NAME

SANK NAME AOORESS

IITIOI"e than one.

AOORESS

Form 3782 (Rev. 7-96) Routing: White - State WIC Office, Yellow - Local Agency, Pink - Vendor
VN -106

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK
WIC VENDOR NUMBER

Page 2 of 3

THE PHARMACY VENDOR HEREBY AGREES AND COVENANTS AS FOLLOWS:
A. Upon notification from the Local Agency. to supply, within a time period agreed upon by the Pharmacy and .the Local Agency. the necessary supply of any one of the "Special Infant Formulas".
B. That all prices will be clearly marked either on the food item or prominently displayed. C. To accept WlC vouchers for payment of the purchase of only eligible WIG formulas. In addition. the vendor must accept all valid WIG
vouchers. D. To accept no WIC vouchers as payment on past or present credit account(s).
E. To accept no WIG vouchers from participants presented after thirty (301 days from the issuance date or prior to issue date shown on the voucher.
F. To accept only vouchers which contain a Georgia WlC Program SEAL G. To refuse acceptance of any food instrument on which any alterations have been made. H. To sell WIC formula at or below the normal pharmacy shelf price. but not to exceed the maximum amount listed on the voucher (excluding infant for
mula vouchers).

To perm11 WlC Program participants to purchase eligible formula without making other purchases and to accord such participants the same

courtesy given to other pharmacy customers.



J. To keep all information conlldentat on Wit; part1crpants.

K. To direct Questions concerning payment. program operations. etc.. to the Local AgencJ: participants will not be contacted concerning these

or other problem areas. (Vendors shall not seek restitution from participants for vouchers not paid by the State.)

L To ensure that no exchange of money between the pharmacy and participant takes place during a WlC voucher transaction.

M. To allow no rainchecks or exchanges of any voucher for cash. credit coupons, stamPS. premiums. or nonlisted formula: however. a Vendor

is not precluded from giving or accepting coupons. stamps. or premiums with purchases as if purchased with cash.

N. To obtain at the time of ourchase an original customer signature on the WlC voucher and reauest the participant to show a WlC identification

card before the purchase of WlC formula can be completed. If the customer is unable to show a WlC identifcation card bearing the same

signature as signed on the voucher. the Vendor should not accept the WlC voucher as payment for the formula.



0. To insert in ink. the actual cost of the WlC formula on the WlC voucher lace at the time of purchase in the presence of the customer.

P. To starrp all vouchers with the authorized vendor stamp (ptOVided by the Local Agency) before depositing in the bank and to deposit all

WlC vouchers in a timely manner. preferably within fifteen ( 15) days of redemption but not more than sixty (60) days from the date of

issuance shown on the voucher face.

0. 1. To distribute to all employees involved in the Vendor'~ WlC Program participation all communications received from the Local Agency

pertinent to the employee's Involvement in the WlC Program. To instruct cashiers. and all other employees. involved in the Vendor's WlC

Program participation of the eligible formula and the correct processing of WlC vouchers.

2. The Vendor will be accountable for actions of employees in the utilization of vouchers or provisicn of supplemental foods.

3. A pharmacy owner or manager who signs an authentic W1C Vendor AgreemenUContract in the absence of a !ocaJ or state agency WlC representative must have his/her Vendor Agreement/Contract signed in the presence of a Notary Public whose Commission does not expire prior to
the date that the Agreement/Contract is signed.

R To abide by rules and regulations of Federal, State and Local Agencies and all procedures as outlined in the WIC Pharmacy Handbook. S. 1. That the State Agency may ceny payments to tne vendor tor 1mproper toed vouchers or may demand refunds tor payments already
rrode on improper vouchers.

2. To reimburse the State Agency wi!hin thirty (30) days of notification for amounts paid by the State Agency on WlC Program food

vouchers processed by the Vendor which are above the normal shelf price of formula. T. To allow representatives of the Local. State, or Federal Agency to monitor the Vendor's pharmacy in an unannounced manner at any time

the pharmacy is open for business. All records pertinent to this Agreement will be made available for review by the representative of the

agency.
u. That vendor stamps are the property of the State of Georgia and that said stamps will be returned to the WlC Program immediately upon
termination/suspension/disQualification/~luntary withdrawal from program participation.
v. 1. That the vendor or the vendor's employee(s) will not reimburse WlC parlicipants or exchange WlC formula. when WlC vouchers were

used for the purchase unless:



a Notified in writing by a health department representative.

b. The vendor is exchanging a WlC purchased item(s) due to inappropriately selling OU1-of-date WlC formula. 2. That any out-of-date formula will be removed from stock and replaced with formula that have expiration dates which do not exceed

the period of normal expected usage.
w. That any Vendor disQualified from another FNS Program shall be disQUalified from participation in the WlC Progiam for the same period of
time. up to three (3) years. X. A Vendor who commits fraud or abuse of the pnograrn is r~able to prosecution under applicable federal. state or local ilMs. Those who
have willfully misapplied. stolen, or fraudulently obtained WlC funds shall be subject to a f~ne of not more than $10,000, or imprisonment

for not more than fiVE! (5) years, or both. Y. To notify the Local Agercy of changes in management or when the Vendor ceases operation or ownership changes. This Agreement is null

z. and void if ownership changes. State of Georgia or Local Sales Taxes will not be collected on formula items purchased with WlC vouchers. AA. To declare 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 WlC 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 pharmacy's store name. as listed on the front page of this contract/agreement. on tne outside of the store building/facility.

AC. To abide by the U.S. Patent and Trademarl< laws. which prohibits unauthorized use of the WlC acronym and logo (refer to Registration Number 1.630,468, provided in 42 U.S.C. 1876, 15 U.S.C. 1051 et sea. and 7 CFR Part 246).

Form 3782 (Rev. 7-96) Routing: White - Stale WIC Office, Yellow - LDeal Agency, Pink VendOI'
VN -107

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARMACY HANDBOOK
WIC VENDOR NUMBER

Page 3of 3

Name and Title of relative that represents the Georgia WJC Program or employed by the Georgia WJC Program:

Office address of relative that represents the Georgia WIC Program or employed by the Georga WIC Program:

Phone Number (office): 1,._- - - - ' - - - - - - - - - - - - - - - - -
(Please attach additional page(s) ~ necessary)
11. 'THE LOCAL AGENCY HEREBY AGREES AND COVENANIS AS FOLLOWS:
A. To instruct the 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 for disbursement to WJC Program participants and to issue updates to this
Formula List as they occur. C. To provide educational material about the WlC Program to the Vendor. D. To instruct WJC participants and proxies in proper use of WJC 1100chers.
E. To ensure that an authorized participant or proxy signature is affixed to any manual voucher prier to releasing the iloucher for redemption. F. To notify the Vendor with a copy of any changes in 1100Chers or use of vouchers and any changes in the Federal and State Regulations
that may affect the Vendor. and to provide the Vendor with a copy of any WlC regulation(s) or policy issuance(s) affecting the Vendor"s
participation in the WJC Program.
G. To assist the Vendor wijh any problem relating to the WJC Program. H. To provide the Vendor with a uniquely numbered stamp.
IlL BOlli PARTIES AGREE AND COVENANT AS FOLLOWS:
A. That :-.o conCict of interest exists between the Vendor and the Local Agency {See Section 1.. AS.). 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 Agency affecting the Vendor"s ability to participate in the WlC Program
under the terms of this Agreement D. The pericd of this Agreement is set forth on the signature page. New agreements win be executed each year. E. This Agreement shan become nuU and void in its entirety upon any changes of ownership of Pharmacy. F. This Agreement may be canceled by eijher party with thirty {30) days written notice. G. In the event of termination of funds by the funding agency to the State Agency for the WJC Program, this Agreement terminates immediately. H. That neaher the Local I>I;Jency nor the Vendor have an obligation to renew the Vendor Agreement. L This agreement/contract does not constitute a license or property interest The relationship between the Local />I;Jency and the Vendor
ends wah the expiration date of this agreement/contract
IV. SANCTIONS AND APPEAL PROCEDURES:
A. SANCTIONS vendors shall be cfiSQUalifled from WJC Program participation for a pericd of UP to three {3) years ~ violations occur during a compliance purchase. monitoring visit by a WlC representative. or Food Stamp Program participation. Procedures lor imposing the sanctions are outUned in the WJC Pharmacy Handbook. Any vendor disQualified from WJC participation may be disQUalified from Food Stamp Program participation.
Refer to 7 CFR 278.
a APPEAL PROCEDURE
vendors are entitled to a fair hearing upon disQualifocation from the WJC Program. Any vendor requesting a fair hearing must contact the Local Agency by telephone. and contact the State WlC Office in writing wahin fifteen {15) days after the action which is being taken.
V. TERMINATION POUCIES:
A. A Vendor shall be terminated from WJC Program participation if the store is tiQ!. riCensed by the Georgia DeQa!tment of Agriculture. B. A Vendor shall be terminated from WJC Program participation if the store is not eligible lor Food Stamp Program participation/authorization
or a Vendor is withdrawn from Food Stamp Program participation.
Fonn 3782 (Rev. 796) Routing: White State WIC Office, Yellow I.Dcal Agency, Pink Vendor
VN -108

District/Unit/Clinic:_ _ _ __ County:_ _ _ _ _ _ __ Date of Incident:_ _ _ _ __ Date Reported:,_ _ _ _ _ __ Follow-up Date fmon Filing Complaint Name: Address:
Phone:( )
JncldenUComplalnt:
i
......
0 \0
Local Agency Resolution:

~t:OR~IA OtrARTMNT OP IIUMAN At:SOURCJ:S
WICPitOGitAM
INCIDENT/COMPLAINT FORM

~art!dponl Jnfqrmati!!D Name: Guardian: WIC J.D. Number: DOB: Phone:( )

Vendor Jnformafl!!n Vendor/Vendor#: Employee Name:
Tille: Phone:( )

State WIC Office Resolution/Comments:

Follow-up Report:

SWO Customer Servjl:e Coordinator:

FORM 3777. Revised 7./95

Routing: OrlglnlalState WIC Office, Yellow-District WIC Office, PlnkWIC Clinic

> ~ ~

(j

Type ofComplolnt;

~

Participant [ ]
Vendor [ 1

~

Local Agency/State WJC Office Staff [ 1

(j

t;lj

L!!rol Ag~nrvLSiol~ WJC

~

lnrorm!!tl!!n Staff Name: Phone: ( )

..
!~I I'~~
I I> (j = ~ :>

V1
~
~
'>E
-....}

Signature:

~

,t:l:l

Can Complaint be Closed at Local
Agency?
Yes( I No( I

:,o0
I~

Signature and Title: Date:

Can Complaint be Closed at State
WJCOffice?
Yes() No( I

I

Signature and Title: Date:

g

I I

z <

~

0

Date:

n
0

::t

0.

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-20 cont'd

PHARi\1ACY HANDBOOK

ii
DHR
GEORGIA DEPARTMENT OF HUMAN RESOURCES
State 'WIC Program Office 2 Peachtree St., NW 8th Floor Atlanta, Georgia 30303
1-800-228-9173
Form No. 3809 (Rev. 6/96)

Standards for panicipation in the program are the same for everyone, regardless ofrace, colar, national origin, age, sex, handicap, religious or political belief

VN-110

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-21

CONTRACT ADDENDUM
GEORGIA WIC PROGRAM WIC VENDOR AGREEMENT
CONTRACT ADDENDUM FEDERAL FISCAL YEAR 1997 From October 1.1996 through September30, 1997
The undersigned, a WIC vendor, does certify that as ofthis date its current prices on all voucher types do not exceed the maximum allowable amount as set forth in the attached schedule. Further, the undersigned agrees to comply with the State established pricing guidelines throughout his/her authorization as a Georgia WIC vendor. The undersigned also certifies that it has been informed that its store will be subject to a local agency monitoring visit to verify its compliance with said schedule. The undersigned further acknowledges that any non-compliance with the schedule could result in termination ofsaid contract, disqualification from participation in the WIC Program and liability for repayment of any overpayments.
The undersigned, a WIC vendor, hereby signs on This ___ day of _ _ _ _ _ _ _ _, 19__.

WIC Vendor Signature

Name of store

Vendor#

Notary Public Signature and Seal

Date

Notary Public's Commission Expires

VN-111

GA WIC PROCEDURES MANUAL FY '97

Attachment VN-22

VENDOR SELF TRAINING SIGN-IN SHEET
.Georgia Department of Human Resources DIVISION OF PUBLIC HEALTH WICOFFICE
VENDOR TRAINING INFORMATION FORM
VENDOR SELF TRAINING SIGN-IN SHEET

DISTRICT_ _

UNIT__ VENDOR NUMBER._ _ __

DATE._ _ _ _ __

TYPE OF TRAINING: ANNUAL [ J FOLLOW-UP ( J OTHER._ _ _ _ _ _ _ _ _ _ __ STORE NAME:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

LOCATION OF TRAINING:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

TRAINING CONDUCTED BY:_ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - - - - -

Print Name

Title

Print Name

Title

Vendor owner/manager legally responsible for store authorizes the above designee(s) to conduct WIC vendor training:

Print Name
PRINT OR TYPE EMPLOYEE(S) NAME

Signature TITLE

Title SIGNATURE

Mail this original form and the completed Vendor Training Checklist to the Local WIC Agency

Office in your area by:

, 19_ _.

(Rev. 3-96)

VN -112

TABLE OF CONTENTS
age
I. Authorization ofFoods ................................................... FP-1 II. Prescribing Foods, General ................................................ FP-1
A Contract Versus Non-Contract Formula ................................ FP-1 B. Food Groups ...................................................... FP-2 C. Food Packages .................................................... FP-3 D. Documentation Required ............................................ FP-3 III. Infants ............................................................... FP-4 A. Tailoring ......................................................... FP-4 B. Infants 0 Through 3 Months ......................................... FP-6 C. Infants 4 Through 12 Months ........................................ FP-9 IV. Children/Women with Special Dietary Needs ............................... FP-11 A. Tailoring ........................................................ FP-12 B. Food Package Assignment .......................................... FP-12 C. Standard Manual Food Package ...................................... FP-12 D. Additional Documentation .......................................... FP-12 V. Children 1 to 5 Years .................................................. FP-14 A. Tailoring ........................................................ FP-14 B. Food Package Assignment .......................................... FP-15 C. Standard Manual Food Package ...................................... FP-15 D. Additional Documentation .......................................... FP-15 VI. Pregnant and Breastfeeding Women ....................................... FP-16 A. Tailoring ........................................................ FP-16 B. Food Package Assignment .......................................... FP-17 C. Standard Manual Food Package ...................................... FP-17 D. Additional Documentation .......................................... FP-17 VII. Postpartum, Non-Breastfeeding Women .................................... ,FP-18 A. Tailoring ........................................................ FP-18 B. Food Package Assignment .......................................... FP-18 C. Additional Documentation .......................................... FP-18
REVISED 09196

VIII. Homelessness, Migrancy, And Disaster Situations ............................ FP-19

A. Definition ....................................................... FP-19

B. Assignment Methods .............................................. FP-19

C. Assignment of Food Packages ....................................... FP-20

D. Documentation Requirements ....................................... FP-20

E. Alternate Food Packages ........................................... FP-20

Attachments:

FP-1 Infant Food Packages, Formula Types, Sizes and

Maximum Monthly Amounts ....................................... FP-24

FP-2 Infant Food Packages, Contract Standard Formula

FP-25

FP-3 Infant Food Packages, Non-Contract Soy Formula

FP-29

FP-4 Infant Food Packages, Contract Special Formula ........................ FP-31

FP-5 Infant Food Packages, Non Contract Special Formula .................... FP-34

FP-6 Alternate Food Package for Infants (0-3 Months), Maximum Monthly

Amounts, Contract Standard Formulas ................................ FP-36

FP-7 Alternate Food Package for Infants (0-3 Months) ........................ FP-37

FP-8 Alternate Food Package for Infants (4-12 Months), Contract Standard Formulas,

Maximum Monthly Amounts ....................................... FP-38

FP-9 Alternate Food Package for Infants (4-12 Months) ....................... FP-39

FP-1 0 Women's and Children's Packages, Prescription Maximum Amounts

FP-40

FP-11 Prescription Women's and Children's Packages ......................... FP-41

FP-12 Alternate Food Packages for Children/Women with Special Dietary

Needs and Maximum Monthly Amounts ............................... FP-49

FP-13 AL{!rnate Food Packages For Children/Women with Special

Dietary Needs ................................................... FP-50

FP-14 Children's Food Packages, Maximum Monthly Amounts .................. FP-51

FP-15 Children's Food Packages .......................................... FP-52

FP-16 Alternate Food Packages for Children 1 Through 5 Years

Maximum Monthly Amounts ....................................... FP-57

REVISED 09/96

FP-1 7 Alternate Food Packages for Children 1 Through 5 Years . . . . . . . . . . . . . . . . . FP-58

FP-18 Women's Food Packages, Maximum Monthly Amount ................... FP-59

FP-19 Pregnant and Breastfeeding Women's Food Packages .................... FP-60

FP-20 Alternate Food Packages for Pregnant and Breastfeeding Women

Maximum Monthly Amounts ....................................... FP-65

FP-21 Alternate Food Packages for Pregnant and Breastfeeding Women ........... FP-66

FP-22 Postpartum, Non-Breastfeeding Women's Food Packages,

Maximum Monthly Amounts ....................................... FP-68

FP-23 Postpartum, Non-Breastfeeding Women's Food Packages ................. FP-69

FP-24 Alternate Food Packages for Postpartum, Non-Breastfeeding

Women, Maximum Monthly Amounts ................................ FP-71

FP-25 Alternate Food Packages for Postpartum, Non-Breastfeeding

Women ........................................................ FP-72

FP-26 Georgia WIC Formula Referral Form

FP-73

FP-27 Georgia WIC Approved Food List, Criteria to Evaluate an

Eligible Food Item

FP-76

FP-28 Georgia WIC Approved Foods

FP-77

FP-29 Georgia WIC Approved Alternate Food List

FP-78

FP-30 WIC Approved Formulas/Medical Foods

FP-79

FP-31 Procurement of Hospital Based Formula

FP-81

FP-32 Supplemental Formula Conversion Table .............................. FP-83

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

I. AUTHORIZATION OF FOODS

The State food package tailoring policy is:

A competent professional authority (CPA)* shallprescribe 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.

II. 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 participating in the Georgia WIC Program will be provided with vouchers for a contract standard formula (iron fortified Enfamil or Prosobee.) The contact special formula (iron fortified Lactofree) may be issued when deemed necessary by a qualified health professional. The contract currently provides the following rebate on each can of iron fortified Enfamil,Prosobee or Lactofree purchased:

Concentrate: Powdered: Ready-To-Feed

$2.1957 $0.4387 $0.1888

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.

All "healthy" infants will receive the contract standard formulas, milk based or soy based. The contract standard products are Enfamil with Iron (milk based) and Prosobee with Iron (soy based). Substitutions of a non- contract standard formula (milk based) will not be permitted. Vouchers which specify the physician prescribed formula. Refer to page FP-6-1 0 for

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

information regarding the documentation required for prescription. Whenever medical conditions/diagnosis warrant a change from the contract standard formula to a WIC-approved non-contract soy formula or a special formula (contract or non-contract)}, the WIC Program may provide the infant with formulas.

B. Food Groups

There are six (6) food groups authorized by Federal WIC Regulations. Each of the 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

I

Infants 0 Thr:)~gh 3

111, 112, 113, 121, 123,

Months

133, 134, 143, 193, 216,

222, 223, 299, 102, 103,

203, 206, 208, 223, 233,

140,299,999

II

Inf~nts 4 Through 12

114,115,116,117,118,

!\t; : ... ~hs

126, 131, 136, 137, 146,

196, 217, 221, 224, 225,

299, 105, 106, 107, 128,

204, 205, 207,226, 141,

299,999

III

Children!Women with 311, 312, 313, 314, 315,

Special Dietary Needs 316, 317, 318, 319, 322,

323, 326, 327, 329, 332,

333, 334, 336, 337, 339,

342, 343,346, 347,370,

381,382,383,999

IV

Childrer" 1 to 5 Years

600-607,610,999

V

Pregnant and.

Breastfeeding Women 401-410,999

VI

Postpartum, Non-

Breastfeeding Women 501-504,510,999

VII

Exclusively Breast-

feeding Women

408, 411, 999

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REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97
C. Food Packages
Food Packages translate the foods authorized in each food group into varying quantities within the maximum amounts allowed. See Attachments FP-1, FP-6, FP-8, FP-10, FP-12, FP-14, FP-16, FP-18, FP-20, FP-22 and FP-24.
1. 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 may be prescribed.
Attachments FP-2, FP-3, FP-4, FP-5, FP-7, FP-9, FP-11, FP-13, FP-15, FP-17, FP-19, FP-21,FP-23 and FP-25list 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 package 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.
Clerical and/or other non - CPA staffare not authorized to assign food packages.
D. Documentation Required
1. 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, document specific tailoring instructions for food package 999 in the "Comments" section or in the progress note of participant's health record.

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
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 of a signature stamp is not acceptable.
2. Additional Documentation. Additional documentation is required for:
a. Contract/Non-contract soy or special formulas (e.g. as indicated for chronic diseases or medical conditions)
b. Ready-to-feed formula c. Lactose intolerant women and children requiring more than two
(2) pounds of cheese per month d. Low iron formulas (e.g. as indicated for conditions such as
hemochromatosis, etc.) t;. Hospital based formula f. Disaster situations
III. INFANTS
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.
Neither cow's milk nor goat's milk is authorizedfor infants in the first 12 months oflife.
A. Tailo:rng
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 ~reastmilk 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 offormula may be assigned to breastfed infants by the CPA. The need for the ma:ximuni 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.

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

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 (1 0) milligrams of iron per liter offormula at standard dilution which supplies sixty-seven (67) kilocalories per one-hundred (1 00) milliliters; i.e. approximately twenty (20) kilocalories per fluid ounce offormula at standard dilution.

All formulas and medical products authorized for distribution through the WIC Program must first be determined WIC - eligible by the Food and Consumer Service, United States Department of Agriculture. The Office ofNutrition then approves distribution of the product through the Georgia WIC Program. For a list ofWIC approved infant formulas see Attachment FP-30.

WIC approved non contract soy or special formulas and medical foods

designed for enteral feeding 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, malabsorption syndrome, allergies and hematological

disorders.

Examples of additional acceptable medical

conditions/diagnoses can be. found in a ICD-9-CM publication

(lnternationa] C1assification of Diseases, 9th Revision; C1inica1

Modification.) Low-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.

For guidance in assessing infant formula tolerance consult the Department of Human Resources Protoco] For Infant Fonnu]a Into1erance and the Office ofNutrition, Nutrition Guide1ines for Practice.

The amount of formula required (including calorie and protein needs) is

based on the infant's total body weight. Infants require approximately

fifty (50) calories per pound ofbody weight. A general recommendation

is to provide 2 Y2 ounces of iron-fortified formula per pound of body

weight, or 5.5 ounces per kilogram ofbody weight, when formula is the

only source of calories.

'

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
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 Attachments FP-1 and FP-6. 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. .Iui..ce. 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.
1. Food Package Assignment. The food packages for infants 0 through 3 months ofage are listed on Attachments FP-2. FP-3, FP-4, FP-5 and FP7. The use of the contract standard formula is required unless a noncontract soy or special formula (contract or non-contract) is prescribed by an appropriate provider for a documented medical condition/diagnosis. The food package numbers are:
a. No formula: 299 b. Contract standard formula: 112, 113, 123, 216, 222, 223, 140 and
999 c. Non-contract Soy formula: 143, 193 d. Contract special formula: 102, 103, 203, 206, 208, 233 e. Non-contract special formula: 111, 121, 133, 134 and 999
2. Standard Man.~~~ 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 Form. The standard manual food package for infants (food package 113) 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.

FP- 6

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

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.
3. 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), contract or non-contract special formula, hospital based formula, ready to feed formula or low iron formula.
a. Contract or Non-contract Special fonnula!Non-contract soy fonnula.
(1) 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 Fonn stating the name ofthe alternative formula and the medical condition/diagnosis. Orders must have an original signature of the physician or licensed/certified health professional working under standing order. Prescription pads with preprinted or prestamped noncontract formula orders will not be accepted.
(2) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). 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.
(3) A current order is required 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

FP -7

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
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 altemati.:; 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 order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). 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 of the formula, the diagnosis (physical condition) and the expiration date of the order.
c. Ready-to-feed formula.
(1) 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.
d. Low iron formula.
(1) Low iron or no iron formula may be indicated for infants with hemochromatosis, hemosiderosis, or neonatal iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis, and those infants requiring frequent transfusions.

FP- 8

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
(2) Low iron formula is NOT authorized for: colic, spitting up, vomiting, cramps, constipation, diarrhea or fussiness nor is it authorized for healthy partially breast fed infants.
C. Infants 4 Through 12 Months
Food Group II consists of formula, iron-fortified cereal, and juice.
1. 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-5and FP9. The use ofthe 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 fonnula: 221 and 299 b. Contract standard fonnula: 115, 116, 117, 118, 126, 217, 221,
224,225, 141 and 999 c. Non-contract soy formula: 146, 196 d. Contract Special formula: 105, 106, 107, 128,204,205, 207,226,
999 e. Non- contract special formula: 114, 131, 136, 137 and 999
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 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 (contract or non-contract), hospital based formula, ready-to-feed formula or low iron formula.
a. Contract or Non-Contract Special Fonnula/Non-Contracf Soy Fonnula

FP- 9

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97
(1) 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 ofthe alternative formula and the medical condition/diagnosis. 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 noncontract formula orders will not be accepted.
(2) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). 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.
(3) A current order is required 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-contract 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 ofHuraan Resources Protocol on Infant Formula Intolerance may:
(a) Recommend to a physician/certified nurse nractitioner/ midwife/specialist a suitable alternative ;:,Jrmula, or
(b) Refer a participant to a physician/certified nurse practitioner/midwife/specialist for evaluation.

FP -10

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
b. Hospital based Fonnula.
(1) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). 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 or 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 fonnula.
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.
d. Low iron fonnula.
(1) Low iron or no iron formula may be indicated for infants with hemochromatosis, hemosiderosis, or neonatal iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis, and those infants requiring frequent transfusions.
(2) Low iron formula is NOT authorized for colic, spitting up, vomiting, cramps, constipation, diarrhea or fussiness nor is it authorized for healthy partially breastfed infants.
IV. CHILDREN/WOMEN WITH SPECIAl. DIETARY NEEDS
Food Group III consists of formula, iron-fortified cereal, and single strength juice.
A. Tailoring
Due to the varying ages and conditions, tailoring for this package must be carefully individualized.

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
1. Fonnula. WIC-approved fonnulas designed for enteral feeding and prescribed by a physician may be authorized. Fonnulas designed for parenteral infusion are not authorized for distribution by the WIC Program. Also, formula may not be authorized solely for the purpose of enhancing nutrient intake or managing body weight (yf children and women participants. The WIC Program does not prohibit the use of authorized formulas for tube fed individuals. For a list ofWIC approved formulas see Attachment FP -30.
2. Cereal. A maximum of thirty-six (36) ounces of cereal per month is authorized.
3. .luic.e. 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 Attachments FP-11and FP-13. The food package numbers are 311, 312,313,314,315,316,317,318,319,322,323,326,327,329,332,333,334, 336, 337, 339, 342, 343, 346, 347, 370, 381, 382, 382, and 999. Formula types, sizes and amounts as well as amounts for cereal and juice are included in Attachments FP-10 and FP-12.
C. Standard Manual Food Package
There is no standard manualfood package for 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 formula or low iron formula.
1. .CO.ntract or Non-contract Special Formula/Non-contract Soy Fommla (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 stating the name ofthe alternative formula and the medical condition/ diagnosis. A prescription expiration date is also recommended. Orders must have an original signature ofthe physician or a licensed/certified health professional working under an MD's orders. Prescription

FP -12

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
pads with preprinted or prestamped non-contract formula orders will not be accepted.
(b) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). 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 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 of a verbal order must be documented in the participant's health record.
3. Registered or Licensed Dietitians following the Department ofHuman Resources Protocol on Infant Feeding Problems 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.
4. Hospital based formula
a. A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). A current order is required at least every three (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 ofthe formula, the diagnosis (physical condition) and the expiration date ofthe order.
5. Ready-to-feed Formula.

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GA WIC PROCEDURES MANUAL FFY '97
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.
6. Low iron Formula.
(a) Low iron or no iron formula may be indicated for clients with he:,e>chromatosis, hemosiderosis, or iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis and those participants requiring frequent transfusions.
(b) Low iron formula is NOT authorized for colic, spitting up, vomiting, cramps, constipation, diarrhea or fussiness nor is it authorized for healthy partially breastfed children.
7. Additional Formula. The need for additional formula above the maximum must be documented by the CPA in the participant's health record. See Attachments FP-10 and FP-12 for maximum formula amounts.
V. CHILDREN 1 TO 5 YEARS
Food Group IV is for children 1 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.
1. 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 211crease requirements. To meet the nutrient needs of

FP -14

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
these children, food packages containing the larger amounts of foods are recommended.
2. Decreased Need. The very young child or the inactive child may not require the maximum amounts of foods allowed, therefore a food package containing reduced amounts of food 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 Attachments FP-15 and FP-17. The food package numbers are 600-607, 610 and 999. Refer to Attachments FP-14 and FP-16 for the maximum amounts ofeach 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 fo.od package for children is food package 603. 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:
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. Examples of additional acceptable medical conditions/diagnoses can be

FP -15

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97
found in a ICD-9-CM publication, (International Classification of Diseases, 9th Revision; Clinical Modification). 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 (i.e. 600) and/or to modify the type of food (i.e. lowfat milk) given to the participant.
VI. PREGNANT AND BREASTFEEDING WOMEN
Food Group V consists of milk, cheese, cereal, 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.
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 of the 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.

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GA WIC PROCEDURES MANUAL FFY '97
B. Food Package Assignment
The food packages for prenatal and breastfeeding women are listed on Attachments FP-19 and FP-21. The food package numbers are 40.1-408, 410 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. If at any time the mother request formula supplementation, the CPA should change the food package ofthe mother and infant to reflect the change in their status. Refer to Attachments FP-18 and FP-20 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:
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. Examples of additional acceptable medical conditions/diagnoses can be found in a ICD-9-CM publication, International Classification of Diseases, 9th Revision; Clinical Modification). 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 a minimum food package (i~e. 401) and/or to modify the type of food (i.e. lowfat milk) given to the participant.

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
VII. POSTPARTUM, NON-BREASTFEEDING WOMEN
Food Group VI consists of milk, cheese, cereal, juice, and eggs.
A. Tailoring
Generally, this group ofparticipants 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 of foods allowed.
2. Decreased Need. The inactive individual may not require the maximum amount of food allowed, therefore a food package containing reduced amounts of food 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.
B. Food Package Assignment
The food packages for postpartum, non-breastfeeding women are listed on Attachments FP-23 and FP-25. The food package numbers are 501-504,510 and 999. A postpartum, non-breastfeeding food package must be issued to the participant no later than six (6) weeks postpartum. Refer to Attachments FP22 and FP-24 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. Examples of additional acceptable medical conditions/diagnoses can be found in a ICD-9-CM publication, (International Classification of Diseases, 9th Revision; Clinical Modifications). A current prescription from a physician is required prior to issuance of a special food package.

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REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

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 (i.e. 501) and/or to modify the type of food (i.e. lowfat cheese) given to a participant.

VIII. HOMELESSNESS, MIGRANCY AND DISASTER SITUATIONS:

A. Local agencies have the option to convert participants to an alternate food package under the following circumstances:

1. A participant lacks a fixed and regular nighttime residence.

2. A participant's primary nighttime residence is:

a. A publicly or privately operated shelter designated to provide temporary living accommodations.

b. A temporary accommodation in the residence of another individual.

c. A public or private place not designed for or ordinarily used as a regular sleeping accommodation.

3. A participant primary residence lacks refrigeration and/or contains a contaminated or limited water supply.

B. Assignment Method. The CPA must evaluate and assign food packages as follows:

1. At each WIC assessment/certification visit.

2. When medically necessary.

3. At the request of the participant.

4. When the participant locates a permanent residence with adequate

refrigeration and/or a safe water supply.

'

Clerical and/or other non-CPA staffare not authorized to assign food packages.

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REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97
C. Assignment of Food Package The CPA may assign the computer food package number that coincides with the quantity/items desired. If a computer food package is unable to meet the needs ofthe participant, the CPA specifies the quantities/items desired and assigns a food package 999. A food package 999 should not exceed the maximum monthly amount per item or include unapproved combinations of WIC foods. If retail purchase is not an option, direct distribution measures will be considered. The local agency, State WIC Office and the Office of Nutr :on should be consult J to discuss this option.
D. Documentation Requirements
1. General Documentation
a. During the WIC assessment/certification, the CPA must write the food package number in the space provided on the WIC Assessment/ Certification Form. Also, if a food package 999 is assigned, document specific tailoring instructions in the "Comments" section of the form or in the progress note of the participant's health record.
b. Between WIC Assessments/Certifications, the CPA must document food package changes in the "Comments" section provided on the form. Date and sign (including title) any changes. The use of a signature stamp is not acceptable.
2. Additiona1 Documentation. Additional documentation is required in the participant's health record for the following:
a. Contract/Non-contract special formulas b. Low iron formulas c. Hospital based formulas. d. Disaster situations
E. Alternate Food Packages
1. Infants 0 Through 3 Months
a. Food packages for this age group consists of ready-to-feed formula only. No cereal or juice is authorized for this age group. The food packages for these infants are listed on Attachment FP-7. Breastmilk is the best food for the normal infant. Infant formula should not be provided to breastfeeding participants unless requested. If a mother chooses to supplement her breastfeeding

FP -20

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

with infant formula, powdered formula is recommended. However ready-to-feed is available. The use of the contract standard formula is required unless a contract or non-contract formula is prescribed by an appropriate provider. The food package numbers are:

(1) No formula:

299

(2) Contract standard formula:

140

(3) Contract special formula:

999

(4) Non-contract special formula:

999

b. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from the contract standard formula to a contract or non-contract special formula, non-contract soy formula, a hospital based formula, or a low iron formula. See FP-7 and FP-9 for specific documentation requirements.

2. Infants 4 Through 12 Months

a. Food packages for this age group consists of ready-to-feed formula, iron fortified infant cereal and 100%, vitamin C fortified JUICe. The food packages for these infants are listed on Attachment FP-9. Breastmilk is the best food for the normal infant. Infant formula should not be provided unless requested. If a mother chooses to supplement her breastfeeding with infant formula, powdered formula is recommended. However, ready-tofeed formula is available. The use of the contract standard formula is required unless a contract or non-contract formula is prescribed by an appropriate provider. The food package numbers are:

(1) No formula:

299

(2) Contract standard formula:

141

(3) Contract special formula:

999

(4) Non-contract special formula: 999

b. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from the contract standard to a contract or non-contract special formula a non-contract soy formula, a hospital based formula or a low iron formula. See FP-8 thru FP-9 for specific documentation requirements.

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
3. Children/Women with Special Dietary Needs
a. Food packages for this group consist of formula, iron fortified cereal and 100%, vitamin C fortifiedjuice. The food packages for these participants are listed on Attachment FP-13. Due to the varying ages and conditions, food packages must be carefully individualized to meet the participant's nutritional needs and food preferences. The food package numbers are: 370 and 999.
b. Additional documentation is required in the participants' health record. See FP-12 thru FP-14 for specific documentation requirements.
4. Chj]dren 1 To 5 Years
a. Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100%, vitamin C fortified juice, and peanut butter. The food packages for these participants are listed on Attachment FP-17. General nutrient requirements for children vary with age, nutritional risk and stage of development. Food packages must be assigned based on individual needs. The food package numbers are 610 and 999.
b. Additional documentation is required with a diagnosis of a chronic disease, developmental disability/congenital defect, inborn error of metabolism or any medical condition that interferes with the ingestion, absorption or utilization of nutrients which requires a therapeutic diet. See FP-17 for specific documentation requirements.
5. Pregnant and Breastfeeding Women
a. Food packages for this group consists of ultra high temperature (UHT) milk, iron fortified cereal, 100%, vitamin C fortified juice, and peanut butter. Food package 410 may be assigned to pregnant and breastfeeding women. Exclusively breastfeeding women receive additional items such as canned tuna, canned beans/peas and canned carrots. The food packages for these participants are listed on Attachment FP-21. Food package 411 may be assigned to all women who are exclusively breast-feeding infants who do not receixe any infant formula from the WIC program. If at any time the mother request formula supplementation, the CPA should change the food package of the mother and infant to reflect the

FP -22

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97 .
change in their status. The food package numbers are 41 0, 411 and 999.
b. Additional documentation is required with a diagnosis of a chronic disease, developmental disability/congenital defect, inborn errors of metabolism or any medical condition that interferes with the ingestion, absorption or utilization of nutrients which requires a therapeutic diet. See FP-17 for specific documentation requirements.
6. Postpartum, Non-Breastfeeding Women
a. Food packages for this group consists of ultra high temperature (UHT) milk, iron fortified cereal, 100%, vitamin C fortified juice, and peanut butter. Food packages for these participants are listed on Attachment FP-25. These food packages are be issued to participants who are greater than or equal to six (6) weeks postpartum. The food package numbers are 510 and 999.
b. Additional documentation is required with a diagnosis of a chronic disease, developmental disability/congenital defect, inborn error of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients which requires a therapeutic diet. See FP-18-19 for specific documentation requirements

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-1

INFANT FOOD PACKAGES

FORMULA TYPES, SIZES AND MAXIMUM MONTHLY AMOUNTS

All types (including prescription)

A. TYPE1

SIZE2

MAXIMUM AMOIINTS3

Concentrate

13 ounces

31 cans, 403 ounces concentrate 01 806 ounces reconstituted 26.9 ounces per day

Ready-To-Feed Powdered4

32 ounces 16 ounces (1 pound)

25 cans 800 ounces 26.7 ounces per day
8 cans

14 ounces

9cans

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

FOOD

SIZE

MAXIMUM AMOUNTS

Infant Cereal

8 ounces

24 ounces

Single Strength Juice

46 fluid ounces OR

92 fluid ounces

Frozen Concentrated Juice

12 fluid ounces

96 fluid ounces, reconstituted

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REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-2 con't

INFANT FOOD PACKAGES CONTRACT STANDARD FORMULA

FOOD PACKAGE NUMBER
112 25 CANS 32 OZ READY TO FEED FE FORTIFIED ENFAMIL ORPROSOBEE
113 *
31 CANS 13 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE
* STANDARD MANUAL
115 25 CANS 32 OZ READY TO FEED FE FORTIFIED ENFAMIL ORPROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL
116 31 CANS 13 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

062

FORMULA: : 12-32 OZ CANS READY TO FEED IRON

_____________ J:_ _F_O_R_T_I_F_I_E_D__E_N_F_A_M__I_L_O_R__P_R_O__S_O_B_E_E___ _

NO LOW IRON FORMULA ALLOWED

063

FORMULA: : 13-32 OZ CANS READY TO FEED IRON

--------------:LF-O-R--T-IF-I-E-D--E-N--F-A-M--IL--O-R--P-R-O--S-O-B-E--E---

NO LOW IRON FORMULA ALLOWED

064

FORMULA: : 15-13 OZ CANS CONCENTRATED IRON

_____________J:__F_O_R_T_I_F_I_E_D__E_N_F_A_M__I_L_O__R_P_R_O__S_O_B_E_E___ _

NO LOW IRON FORMULA ALLOWED

065

FORMULA: : 16-13 OZ CANS CONCENTRATED IRON

_____________J:_ _F_O_R_T_I_F_I_E_D__E_N_F_A_M__I_L_O__R__P_R_O_S_O__B_E_E__ _

NO LOW IRON FORMULA ALLOWED

067

FORMULA:

!: 13-32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

~~~~~~-----1_~!~:~~~~~-~: _______________ _

NO LOW IRON FORMULA ALLOWED

071

FORMULA:

!: 12-32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL OR PROSOBEE

~~~~-------l~.:~:.?_~~~~!~~~~~-~~~~-~~-~~~-

NO LOW IRON FORMULA ALLOWED

068

FORMULA:

!: 16-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

~~~~~~-----1_~!~:~~~~~~~: _______________ _

NO LOW IRON FORMULA ALLOWED

072

FORMULA:

!: 15-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

: PROSOBEE

JUICE:

I I
: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

-------------~----------------------------------

NO LOW IRON FORMULA ALLOWED

FP -25

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-2 con't

FOOD PACKAGE NUMBER
117 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE
118 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 16 OZ INF i\NT CEREAL

123 8-16 OZ CANS POWDER ENFAMIL OR 9-14 OZ CANS POWDER PROSOBEE (IRON FORTIFIED)

126 8-16 OZ CANS POWDER ENFAMIL OR 9-14 OZ CANS POWDER PROSOBEE (IRON FORTIFIED)

2 CANS JUICE

'

24 OZ INFANT CEREAL

VOUCHER CODE
069

VOUCHER MESSAGE
FORMULA: II 16-13 OZ CANS CONCENTRATED IRON
1 FORTIFIED ENFAMIL OR PROSOBEE _JU__IC__E_: _____JI__1_-1_2__O_Z__C_A_N__F_R_O_Z_E_N__O__R__1-_4_6_O__Z_C_A__N___ _

NO LOW IRON FORMULA ALLOWED

072

! ' -,RMULA: I 15-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR PROSOBEE

~~-~~~-----1!~~:.?~~~~!~~~~~-~~~~-~:-~~~---

NO LOW IRON FORMULA ALLOWED

072

! FORMULA: I 15-13 OZ CANS CONCENTRATL ..i IRON FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

1 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I

I I
-----------~-----------------------------------NO LOW IRON FORMULA ALLOWED

090

! FORMULA: I 16-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR PROSOBEE

JUICE: CEREAL:

1 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I UP TO 16 OZ INFANT I

-----------~------------------------------------
NO LOW IRON FORMULA ALLOWED

091

FORMULA: I 4-16 OZ CANS POWDER ENFAMIL OR 5-
! 14 OZ CANS POWDER PROSOBEE
____________________ -----------1~~~?~-~~~~:~~~l

NO LOW IRON FORMULA ALLOWED

! 491

FORMULA: i~1~~~;~~b=:~:~~~~ OR 4-

-----------1~~?~-~~~_!._~~~l----------------- --

NO LOW IRON FORMULA ALLOWED

091

! FORMULA: I 4-16 OZ CANS POWDER ENFAMIL OR 514 OZ CANS POWDER PROSOBEE

-----------1~~~?~-~~~~:~~~2--------------------

NO LOW IRON FORMULA ALLOWED

491

! FORMULA: I 4-16 OZ CANS POWDER ENFAMIL OR 414 OZ CANS POWDERPROSOBEE

-----------1~~~?~-~~~~!:~~~l ___________________ _

NO LOW IRON FORMULA ALLOWED

073

JUICE: CEREAL:

!I 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

I UP TO 24 OZ INFANT

FP- 26

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-2 con't

FOOD PACKAGE NUMBER
216 13 CANS 13 OZ CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE

VOUCHER CODE
092

VOUCHER MESSAGE

FORMULA:

ll 13-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

______________ 1_~~~~~~-~~-----------------------

NO LOW IRON FORMULA ALLOWED

217 13 CANS 13 OZ CONCENTRATED FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL
221 2 CANS JUICE 24 OZ INFANT CEREAL
222 1-16 OZ CAN POWDER ENFAMIL OR 1-14 OZ CAN POWDER PROSOBEE (IRON FORTIFIED)

092

FORMULA:

ll 13-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

______________ 1_!~~~~~!:~-----------------------

NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

2-12 OZ CANS FROZEN (OR) 2-46 OZ CANS UP TO 24 OZ INFANT

073

JUICE:

CEREAL:

2-12 OZ CANS FROZEN (OR) 2-46 OZ CANS UP TO 24 OZ INFANT

074

FORMULA:

1-16 OZ CAN POWDERENFAMIL OR

1-14 OZ CAN POWDER PROSOBEE

----------------(-IR--O-N--F-O-R-T-I-T-l-E-D-)-----------------

NO LOW IRON FORMULA ALLOWED

223 3-16 OZ CANS POWDER ENFAMIL OR 4-14 OZ CANS POWDERPROSOBEE (IRON FORTIFIED)

075

______________ l _________________ FORMULA:

l 3-16 OZ CANS POWDER ENFAMIL OR
4-14 OZ CANS POWDER PROSOBEE
l_i~~~~-~~~:~~~2

NO LOW IRON FORMULA ALLOWED

FP -27

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-2 con't

FOOD PACKAGE NUMBER
224 1-16 OZ CAN POWDER ENFAMIL OR 1-14 OZ CAN POWDER PROSOBEE (IRON FORTIFIED) 2CANSJUICE 24 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

076

FORMULA:

1-14 OZ CAN POWDERENFAMIL OR

1-14 OZ CAN POWDER PROSOBEE

(IRON FORTIFIED)

2-12 OZ CANS FROZEN OR

JUICE:

2-46 OZ CANS

UP TO 24 OZ INFANT

-C-E-R--E-A-L-:-----JL----------------------------------

NO LOW IRON FORMULA ALLOWED

225 3-16 OZ CANS POWDER ENFAMIL OR 4-14 OZ CANSPOWDERPROSOBEE (IRON FORTIFIED) 2CANSJUICE 24 OZ INFANT CEREAL
299 BREASTFEEDING
MESSAGE
999 FORMULA AS ORDERED BY A PHYSICIAN FORMULA EQUALS 8 LBS OR 403 OZ CONC. OR 800 OZRTF JUICE: 2-46 OZ OR 2-12 OZ FROZEN CANS CEREAL: 24 OZ FORMULA ONLY MAY BE PRESCRIBED

077

FORMULA:

3-16 OZ CANS POWDER ENFAMIL OR

4-14 OZ CANS POWDER PROSOBEE

(IRON FORTIFIED)

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ

_C_E_R_E_A__L_:_____.__CU_AP_N_T_SO_2_4__O_Z__IN__F_A_N_T________________

NO LOW IRON FORMULA ALLOWED

,__..,.,_"
059
999

NURSE YOUR BABY OFTEN THE MORE YOU BREASTFEED, THE MORE MILK YOU WILL HAVE FOR YOUR BABY
AS PRESCRIBED
A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY

FP -28

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GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-3

INFANT FOOD PACKAGES NON-CONTRACT SOY FORMULA
PRESCRIPTION REQUIRED

FOOD PACKAGE NUMBER 143
31 CANS 13 OZ CONCENTRATE IRON FORTIFIED NONCONTRACT FORMULA
146 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED NONCONTRACT FORMULA 2 CANS JUICE 24 OZ INFANT CEREAL
193
8-16 OZ OR 9-14 OZ OR 10-12 OZ CANS POWDER IRON FORTIFIED NON-CONTRACT FORMULA

VOUCHER CODE 257 258
073 257 258 457
458

VOUCHER MESSAGE

FORMULA: 15-13 OZ CANS CONCENTRATE WITH IRON: ISOMIL, OR CARNATION ALSOY
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 16-13 OZ CANS CONCENTRATE WITH IRON: ISOMIL, OR CARNATION ALSOY
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS UP TO 24 OZ INFANT

FORMULA: 15-13 OZ CANS CONCENTRATE WITH IRON: ISOMIL, CARNATION ALSOY
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 16-13 OZ CANS CONCENTRATE WITH IRON: ISOMIL, CARNATION ALSOY
----------- ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 4-16 OZ CANS OR 5-14 OZ CANS OR 512 OZ CANS POWDER WITH IRON: ISOMIL, CARNATION ALSOY OR GERBER SOY
----------- ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA:

4 (16 OZ OR 14 OZ) CANS OR 5-12 OZ CANS POWDER WITH IRON: ISOMIL, CARNATION ALSOY OR GERBER SOY

NO LOW IRON FORMULA ALLOWED

FP- 29

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-3 con't

FOOD PACKAGE NUMBER
196
8-16 OZ OR 9-14. OZ OR 10-120Z CANS POWDER IRON FORTIFIED NON-CONTRACT FORMULA
2CANSJUICE 24 OZ INFANT CEREAL

VOUCHER CODE 073 457
458

VOUCHER MESSAGE

JUICE: CERf,\L:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS UP TO 24 OZ INFANT

FORMULA: 4-16 OZ CANS OR 5-14 OZ CANS OR 512 OZ CANS POWDER WITH IRON: ISOMIL, CARNATION ALSOY OR GERBER SOY
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED
----------- ----------------------------------
FORMULA: 4-16 OZ CANS OR 5-14 OZ CANS OR' 12 OZ CANS POWDER WITH IRON: ISOMIL, CARNATION ALSOY OR GERBER SOY

FP- 30

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-4

CONTRACT SPECIAL FORMULA-LACTOFREE PRESCRIPTION REQUIRED INFANT FOOD PACKAGES

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

102 25 CANS 32 OZ READY TO FEED FE FORTIFIED LACTOFREE

262

FORMULA: 12-32 OZ CANS READY TO FEED IRON

FORTIFIED LACTOFREE
------------ ----------------------------------

NO LOW IRON FORMULA ALLOWED

263

FORMULA: 13-32 OZ CANS READY TO FEED IRON

FORTIFIED LACTOFREE
------------ ----------------------------------

NO LOW IRON FORMULA ALLOWED

103 31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE

264

FORMULA: 15-13 OZ CAN CONCENTRATED IRON

------------ -F-O-R-T-I-F-I-E-D--L-A-C-T-O--F-R-E-E--------------

NO LOW IRON FORMULA ALLOWED

265

FORMULA: 16-13 OZ CONCENTRATED IRON

FORTIFIED LACTOFREE
----------- ----------------------------------

NO LOW IRON FORMULA ALLOWED

105 25 CANS 32 OZ READY TO FEED FE FORTIFIED LACTOFREE 2 CANS JUICE 24 OZ INFANT CEREAL

267

FORMULA: I2-32 OZ CANS READY TO FEED IRON

FORTIFIED LACTOFREE

I-I2 OZ CAN FROZEN OR I-46 OZ CAN

JUICE:

UP TO 24 OZ INFANT

CEREAL: ------------~----------------------------------

NO LOW IRON FORMULA ALLOWED

27I

FORMULA: 13-32 OZ CANS READY TO FEED IRON

FORTIFIED LACTOFREE

I-I2 OZ CAN FROZEN OR 1-46 OZ CAN

JUICE:

NO LOW IRON FORMULA ALLOWED

106 3I CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 24 OZ INFANT CEREAL

268

FORMULA: 16-I3 OZ CANS CONCENTRATED IRON

FORTIFIED LACTOFREE

I- I2 OZ CAN FROZEN OR 1-46 OZ CAN

JUICE:

UP TO 24 OZ INFANT

CEREAL:
----------------------------------

NO LOW IRON FORMULA

272

FORMULA: I5~13 OZ CANS CONCENTRATED IRON

FORTIFIED LACTOFREE

JUICE:

1-I2 OZ CAN FROZEN OR 1-46 OZ CAN

-----------
NO LOW IRON

----------------------------------

FORMULA ALLOWED

'

FP- 31

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-4 con't

FOOD PACKAGE NUMBER 107
31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE
128 31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 16 OZ INFANT CEREAL
233 9 CANS 14 OZ POWDERED FE FORTIFIED LACTOFREE
226 9 CANS 14 OZ POWDERED FE FORTIFIED LACTOFREE 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 269
272
290
272
291 375
: ~.:}
375 073

VOUCHER MESSAGE

l FORMULA: I ~~~~~~E~A~1c~g~~:TRATED IRON
~ 1-12 OZ CAN FROZEN OR 1-46 OZ CAN _JU__IC__E_: _____JI___________________________________

NO LOW IRON FORMULA ALLOWED

FORMULA ! 15-13 OZ CANS CONCENTRATED IRON 'ORTIFIED LACTOFREE '-12 OZ CAN FROZEN OR 1-46 OZ CAN
_JU__h_.-_.______Jl___________________________________

NO LOW IRON FORMULA ALLOWED

! FORMULA:

I I

16-13 OZ CANS CONCENTRATED IRON

FORTIFIED LACTOFREE

JUICE:

~ 1-12 OZ CAN FROZEN OR 1-46 OZ C. ,:
l UP TO 16 OZ INFANT

CEREAL:

I I

-----------~----------------------------------

NO LOW IRON FORMULA ALLOWED

! FORJvlULA:

I 1

15-13 OZ CANS CONCENTRATED IRON

FORTIFIED LACTOFREE

~ 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

_JU__IC__E_: _____JI..______________,._. ."'~-~ .----------------

NO LOW IRON FORMULA ALLO ;yf::D

FORMULA: I 5-14 OZ CANS POWDERED IRON
___________ 1_!~~:~!~2::~~:~!~~-------------

NO LOW IRON FORMULA ALLOWED

FORMULA: I 4-14 OZ CANS POWDERED IRON
___________ 1_!~~:~!~2::~~:~!~~-------------
NO LOW IRON FORMULA ALLOWED

FORMULA: I 5-14 OZ CANS POWDERED IRON
___________ 1_!~~:~!~2::~-~~~!~~-------------

NO LOW IRON FORMULA ALLOWED

FORMULA: I 4-14 OZ CANS POWDERED IRON
___________ 1_!~~~~!~2::~~:~!~~--------------
NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 CAN OZ FROZEN OR 2-46 OZ CAN UP TO 24 OZ INFANT

FP- 32

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-4 con't

FOOD PACKAGE NUMBER
203
3 CANS 140Z POWDERED FE FORTIFIER LACTOFREE
204
I CAN 14 OZ POWDERED FE FORTIFIED LACTOFREE 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 275
276

VOUCHER MESSAGE

FORMULA I 3-14 OZ CANS POWDERED IRON
_: _________JII__F_O_R_T_I_F_I_E_D__L_A_C_T_O__F_R_E_E_______________ NO LOW IRON FORMULA ALLOWED

FORMULA ~ ~6~~~Ii~~~~~~::D IRON

JUICE: CEREAL:

1 2-12 OZ CANS FROZEN OR 2-46 OZ
I CANS I UP TO 24 OZ INFANT

----------~-----------------------------------

NO LOW IRON FORMULA ALLOWED

205

277

FORMULA 3-14 OZ CANS POWDERED IRON

3 CANS 14 OZ

:

FORTIFIED LACTOFREE

POWDERED FE

FORTIFIED LACTOFREE

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ

2 CANS JUICE

CEREAL: CANS

24 OZ INFANT CEREAL

UP TO 24 OZ INFANT ----------~-----------------------------------

NO LOW IRON FORMULA ALLOWED

206
13 CANS 13 OZ CONCENTRATE FE

292

FORMULA I 13-13 OZ CANS CONCENTRATED IRON

~---------JL!~~:~!~!:~~~:~!~~--------------

FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

207
13 CANS 13 OZ

292

: ! FORMULA I 13-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

CONCENTRATE FE FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

2CANSJUICE

24 OZ INFANT CEREAL

073

JUICE:

2-12 CAN OZ FROZEN OR 2-46 OZ CAN

UP TO 24 OZ INFANT

CEREAL:

208

274

FORMULA 1-14 OZ CANS POWDERED IRON

I CAN 140Z

FORTIFIED LACTOFREE

POWDERED FE FORTIFIED LACTOFREE

NO LOW IRON FORMULAALLOWED

FP- 33

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-5

INFANT FOOD PACKAGES NON-CONTRACT SPECIAL FORMULA
Prescription Required

FOOD PACKAGE NUMBER
Ill 8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL
114 8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE
060

FORMULA:

VOUCHER MESSAGE
4-1 LB CANS POWDER PORTAGEN OR PREGESTIMIL

060

FORMULA:

4-1 LB CANS POWDER PORTAGEN OR PREGESTIMIL

060

FORMULA:

060

FORMULA:

4-1 LB CANS POWDER PORTAGEN OR PREGESTIMIL
4-1 LB CANS POWDER PORTAGEN OR PREGESTIMIL

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZCANS

INFANT CEREAL: UP TO 24 OUNCES

121 8 CANS 16 OZ POWDER OR 31-13 OZ CANS CONCENTRATE NUTRAMIGEN OR 25 QTS READY-TO-FEED ALI MENTUM
131 8 CANS 16 OZ POWDER OR 31-13 OZ CANS CONCENTRATE NUTRAMIGEN OR 25 QTS. READY-TOFEED ALIMENTUM 2 CANS JUICE 24 OZ INFANT CEREAL

160

FORMULA:

4-1 LB CANS POWDER OR 15-13 OZ CAN CONCENTRATE NUTRAMIGEN OR 12 QTS READY-TO-FEED ALIMENTUM

161

FORMULA:

4-1 LB CANS POWDER OR t 16-13 OZ CANS CONCENTRATE
NUTRAMIGEN OR 13 QTS READY-TO-FEED ALIMENTUM

160

FORMULA:

4-1 LB CANS POWDER OR 15-13 OZ CANS CONCENTRATE NUTRAMIGEN OR 12 QTS READY-TO-FEED ALIMENTUM

161

FORMULA:

4-1 LB CANS POWDER OR 16-13 OZ CANS CONCENTRATE NUTRAMIGEN OR 13 QTS READY-TO-FEED ALIMENTUM

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46

OZCANS

INFANT CEREAL: UP TO 24 OUNCES

FP- 34

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-5 con't

FOOD PACKAGE

I I VOUCHER

VOUCHER MESSAGE

31 CANS 13 O13Z3

094 !.5:~-~~~~---1~~.:~~9!_~~~~-~9!':.~~~~!~------

CONCENTRATELOWIRON r---------r-L_O_W_I_R_O_N_F_O_RM~U_L_A_A_L_L_O__WE_D______________~

FORMULA

095 !.5:~-~~~~---1~~_:~~9!._~!'-~~-~9!':_~~~_!-~!~------

LOW IRON FORMULA ALLOWED

134 8-16 OZ CANS OR 9-14 OZ CANS POWDER LOW IRON FORMULA

194 ~::_~~~~---l!~~~&1t~1~fi~:~~~~:______
LOW IRON FORMULA ALLOWED

195 ~::_~~~~---1!~~~~~~~~;{_~~:~---------

LOW IRON FORMULA ALLOWED

136 31 CANS 13 OZ

094 !.5:~-~~~~---1~~.:~~9!_~~~~-~9!':.~~~.!-~!~------

CONCENTRATE LOW IRON

LOW IRON FORMULA ALLOWED

FORMULA 2 CANS JUICE

095 !.5:~-~~~---12~.:~~9!_~~~~-~9!':.~~~~!~------

24 OZ INFANT CEREAL

LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS UP TO 24 OZ INFANT

137 8-16 OZ 9-14 OZ CANS POWDER INFANT LOW IRON FORMULA 2CANS JUICE 24 OZ INFANT CEREAL

194

FORMULA:

4-16 OZ CANS OR 5-14 OZ CANS

POWDERED INFANT

LOW IRON FORMULA ALLOWED

195

! FORMULA:

4(16 OR 14) OZ CANS CANS

I
-------------1----------------------------------
LOW IRON FORMULA ALLOWED

073

JUICE:

!: 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

CEREAL:

: UP TO 24 OZ INFANT

999 FORMULA AS ORDERED BY A PHYSICIAN. FORMULA EQUALS 8 LBS POWDER OR 403 OZ CONC. OR 8000ZRTF JUICE: 2-46 OZ OR 2-12 OZ FROZEN CANS CEREAL: 24 OZ

AS PRESCRIBED
A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY

FORMULA ONLY MAY BE PRESCRIBED

FP- 35

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

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- 36

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-7

ALTERNATE FOOD PACKAGE FOR INFANTS (0-3 MONTHS)

FOOD PACKAGE NUMBER
140
I00 CANS 8 OZ READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

VOUCHER CODE 240 240 240 240 241 241 241 241

VOUCHER MESSAGE
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
----------- ----------------------------------
NO LOW IRON FORMULA ALLOWED
FORMULA: 12-8 OZ CANS READY TO FEED
------------ -E-N-F-A--M-I-L-O--R-P-R--O-S-O-B--E-E-W--I-T-H--IR-O--N---
NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED

FP- 37

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

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- 38

REVISED 09/%

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-9

ALTERNATE FOOD PACKAGE FOR INFANTS (4-12 MONTHS)

FOOD PACKAGE NUMBER

VOUCHER CODE

141

240

100CANS 8 OZ READY TO FEED ENFAMIL OR PROSOBEE WITH IRON 3-8 OZ BOXES OF INFANT 240 CEREAL 12-6 OZ CANS JUICE

240

240

240

242

242

243

VOUCHER MESSAGE

FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
------------ ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
----------- ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 12-8 OZ CANS READY TO FEED

-----------

ENFAMIL OR PROSOBEE WITH IRON
----------------------------------

NO LOW IRON FORMULA ALLOWED

FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
----------- ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
----------- ----------------------------------
NO LOW IRON FORMULA ALLOWED

FORMULA: 13-8 OZ CANS READY TO FEED
----------- -E-N-F-A--M-I-L-O--R-P-R--O-S-O-B--E-E-W--I-T-H--IR-O--N---
NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

1-8 OZ BOX, DRY

JUICE:

6-6 OZCANS

FORMULA:

13-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

INFANT CEREAL:

1-8 OZ BOX, DRY

JUICE:

6-6 OZCANS

NO LOW IRON FORMULA ALLOWED

FORMULA: 14-8 OZ CAN READY TO FEED ENFAMIL OR PROSOBEE WITH IRON
--------~--- ----------------------------------
NO LOW IRON FORMULA ALLOWED

INFANT

'

CEREAL:

1-8 OZ BOX, DRY

FP- 39

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-1 0

WOMEN'S AND CHILDREN'S PACKAGES PRESCRIPTION MAXIMUM AMOUNTS

' A.

FORMlJLA TYPES, SIZES AND ADDITIONAL AMOUNTS

TYPE Concentrate

CAN SIZE 13 ounces

MAXIMUM AMOUNTS
31 cans (403 oz concentrate Or 806oz reconstituted)

ADDITIONAL AMOUNTS
4 can (52 oz concentrate or 104 oz 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

FOOD

SIZE

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 -40

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11

WOMEN'S AND CHILDREN'S PACKAGES

Prescription Required

FOOD PACKAGE NUMBER 3II
8 CANS I6 OZ POWDER PORTAGENOR PREGESTIMIL
3I2 3I CANS 13 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE
313 25 CANS I3 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 240ZCEREAL
3I4 25 CANS 32 OZ READY TO FEED FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 240ZCEREAL

VOUCHER CODE

VOUCHER MESSAGE

060

FORMULA:

4-I LB CANS POWDER PORTAGEN OR

PREGESTIMIL

060

FORMULA:

4-I LB CANS POWDER PORTAGEN OR

PREGESTIMIL

064

FORMULA:

I5-13 OZ CANS CONCENTRATED

IRON FORTIFIED ENFAMIL OR

PROSOBEE
------------------------------------------------

NO LOW IRON FORMULA ALLOWED

065

FORMULA:

!: I6-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

_____________ 1_!~~~~~!:~-----------------------

NO LOW IRON FORMULA ALLOWED

078

FORMULA:

!: I2-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

: PROSOBEE

_JU__IC__E_: _______.:I__I_-1_2__O_Z__C_A_N__F_R_O_Z_E__N_O__R__I-_4_6_O__Z_C__A_N_ I

NO LOW IRON FORMULA ALLOWED

079

FORMULA:

!: 13-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

: PROSOBEE

JUICE:

: I- I2 OZ CAN FROZEN OR I-46 OZ CAN

CEREAL:

: UPT0240Z

------------------------------------------------

NO LOW IRON FORMULA ALLOWED

080

! FORMULA:

I2-32 OZ CANS READY TO FEED IRON

: FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

: I- I2 OZ CAN FROZEN OR I-46 OZ CAN

_ _ _ _ _ _ _ _ _ _ _ _ _ JI_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NO LOW IRON FORMULA ALLOWED

08I

! FORMULA:

13-32 OZ CANS READY TO FEED IRON

: FORTIFIED ENFAMIL OR PROSOBEE

JUICE:

: I-I2 OZ CAN FROZEN OR I-46 OZ CAN

_C_E_R_E_A__L_: _____

: .I_
I

_U_P__T_0_2__4_0_Z_______________________

NO LOW IRON FORMULA ALLOWED

'

FP- 41

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11 con't

FOOD PACKAGE NUMBER 315
8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL 3 CANS JUICE 240ZCEREAL
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 2CANSJUICE 360ZCEREAL

VOUCHER CODE

VOUCHER MESSAGE

060

FORMULA:

4-1 LB CANS POWDER PORTAGEN OR PREGESTIMIL

060

FORMULA:

4-1 LB CANS POWDERPORTAGEN OR PREGESTIMIL

066

JUICE:

CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS UP TO 24 OUNCES

082

FORMULA:

!;~~~ ~~~~~I~g~N~!~~iZD

l PROSOBEE

JUICE:

l 1-12 OZ CAN FROZEN OR 1-46 OZ

l CAN

----------------~------------------------------

NO LOW IRON FORMULA ALLOWED

083

FORMULA:

16-13 OZ CANS CONCENTRATED

IRON FORTIFIED ENFAMIL OR

PROSOBEE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ

CAN

:.:EREAL:

UP TO 24 OUNCES

----------------~------------------------------NO LOW IRON FORMULA ALLOWED

082

FORMULA:

!l 15-13 OZ CANS CONCENTRATED IRON FORTIFIED ENFAMIL OR

l PROSOBEE

JUICE:

l 1-12 OZ CAN FROZEN OR 1-46 OZ

l CAN

----------------~-------------------------------

W~ LOW IRON FORMULA ALLOWED

084

FORMULA:

16-13 OZ CANS CONCENTRATED

IRON FORTIFIED ENFAMIL OR

PROSOBEE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ

CAN

CEREAL:

UPT0360Z

----------------~-----------------------------NO LOW IRON FORMULA ALLOWED

FP -42

REVISED 09/%

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11 con't

FOOD PACKAGE NUMBER
318 9 CANS 16 OZ POWDER OR 35 CANS 13 OZ CONCENTRATE NUTRAMIGEN OR 28 QTS. READY-TO-FEED ALIMENTUM 3 CANS JUICE 360ZCEREAL
319 35 CANS 13 OZ CONCENTRATE FE FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 360ZCEREAL
322 8-16 OZ CANS POWDER ENFAMIL OR 9-14 OZ CANS POWDER PROSOBEE (IRON FORTIFIED)

VOUCHER CODE 170 171 070 084
086
091
491

VOUCHER MESSAGE

FORMULA: FORMULA:

!i 4-1 LB CANS POWDER OR 16-13 OZ CANS CONCENTRATE
i NUTRAMIGEN OR 14 QTS. I READY-TO-FEED ALIMENTUM
!i 5-1 LB CANS POWDER OR 19-13 OZ CANS CONCENTRATE ' NUTRAMIGEN OR 14 QTS.
READY-TO-FEED ALIMENTUM

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZCANS UP TO 36 OUNCES

FORMULA:

16-13 CANS CONCENTRATED

IRON FORTIFIED ENFAMIL OR

PROSOBEE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ

CAN

CEREAL:

UPT0360Z

-----------------~------------------------------

NO LOW IRON FORMULA ALLOWED

FORMULA: ~ ::~~ ~~R~~::~;~~;;~y~~E

i PROSOBEE

JUICE:

i 1-12 OZ CAN FROZEN OR 1 -46 OZ

I CAN

-----------------~------------------------------

NO LOW IRON FORMULA ALLOWED

FORMULA:

!i 4-16 OZ CANS POWDER ENFAMIL OR 5-14 OZ CANS POWDER

i PROSOBEE

-----------------L~~?~-~~~~~~:~2 ______________

NO LOW IRON FORMULA ALLOWED

FORMULA:

!i 4-16 OZ CANS POWDER ENFAMIL OR 4-14 OZ CANS POWDER

i PROSOBEE

-----------------L~~~?~-~~~~!~~~2 ______________

NO LOW IRON FORMULA ALLOWED

FP -43

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11 con't

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

323 7-16 OZ CANS POWDER ENFAMIL OR 8-14 OZ CANS POWDER PROSOBEE (IRON FORTIFIED)
3 CANS JUICE 240ZCEREAL
326 8-16 OZ CANS POWDER ENFAMIL OR 9-14 OZ CANSPOWDERPROSOBEE (IRON FORTIFIED) 3 CANS JUICE 240ZCEREAL

066

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS

CEREAL:

UP TO 24 OUNCES

075

FORMULA: 3-16 OZ CANS POWDER ENFAMIL OR

4-14 OZ CANS POWDER PROSOBEE

(IRON FORTIFIED)
------------------------------------------------

NO LOW IRON FORMULA ALLOWED

491

! FORMULA: : 4-16 OZ CANS POWDER ENFAMIL OR 4-14 OZ CANS POWDER PROSOBEE

------------L~~<?~-~9~~~~:~2------------------

NO LOW IRON FORMULA ALLOWED

066

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CANS

UP TO 24 OUNCES

CEREAL:

091

FORMULA: 4-16 OZ CANS POWDER ENFAMIL OR

, 5-14 OZ CANS POWDER PROSOBEE

--------"' ' ..-(I-R-O--N--F-O-R-T-I-F-I-E-D-)----------------- ~~-

NO LOW Ii-~;_::, FORMULA ALLOWED

491

____________ ! __________________ FORMULA:

: 4-16 OZ CANS POWDER ENFAMIL OR 4-14 OZ CANS POWDER PROSOBEE
j_~~~<?~-~9~2:~~:~2

NO LOW IRON FORMULA ALLOWED

327 8-16 OZ CANS POWDER ENFAMIL OR 9-14 OZ CANSPOWDERPROSOBEE (IRON FORTIFIED)
3 CANS JUICE 360ZCEREAL

070

JUICE:

: 3-12 OZ CANS FROZEN OR 3-46 OZ

CANS

CEREAL:

UP TO 36 OUNCES

091

FORMULA: 4-16 OZ CANS POWDER ENFAMIL OR

____________ __________________ 5-14 OZ CANS POWDER PROSOBEE 1_2_~<?~-~9~2:~~:~2

NO LOW IRON FORMULA ALLOWED

491

____________ ! __________________ FORMULA:

: 4-160ZCANSPOWDERENFAMILOR
4-14 OZ CANS POWDER PROSOBEE
j_~~~<?~~~9~~~~:~2

NO LOW IRON FORMULA ALLOWED

FP -44

REVISED 09/%

GA WIC PROCEDURES MANUAL FFY '97

FOOD PACKAGE

I VOUCHER

Attachment FP-11 con't
VOUCHER MESSAGE

329 9-16 OZ CANS POWDER ENFAMIL OR 10-14 OZ CANS POWDER PROSOBEE (IRON FORTIFIED)
3 CANS JUICE 360ZCEREAL
332 31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE
333 25 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 240ZCEREAL
334 25 CANS 320Z READY-TO-FEED FE FORTIFIED LACTOFREE 2CANS JUICE 240ZCEREAL
336 31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 240ZCEREAL

091

FORMULA: i 4-16 OZ CANS POWDERENFAMIL OR

___________ 1_~~~~93::~~!-~~:~~~~:9!::: ____ _

NO LOW IRON FORMULA ALLOWED

093

FORMULA: i 5(14 OZ 16 OZ) CANS POWDER IRON

___________ j_!~~:~!~~~~~~~!~-~~-~~9:~~:~----

NO LOW IRON FORMULA ALLOWED

070

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CEREAL:

CANS

UP TO 36 OUNCES

264

FORMULA: 15-13 OZ CANS CONCENTRATED IRON

FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

265

FORMULA: i 16-13 OZ CANS CONCENTRATED IRON

---------~-1_!~~:~~~~~~:9!~~--------------

NO LOW IRON FORMULA ALLOWED

278

! FORMULA: i 12-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

~~~~-----l!:~:.?_~~~t::!~~~~~-9~~~-~:-~~~--

NO LOW IRON FORMULA ALLOWED

279

! FORMULA: i 13-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

JUICE:

i 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

~~~~~~---l~~~~~~~------------------------

NO LOW IRON FORMULA ALLOWED

280

! FORMULA: i 12-32 OZ CANS READY TO FEED IRON FORTIFIEDLACTOFREE

~~~~-----12:~:.?~~~!~~:~~-9~~~-~:-~~~--

NO LOW IRON FORMULA ALLOWED

281

! FORMULA: i 13-32 OZ CANS READY-TO-FEED IRON FORTIFIED LACTOFREE

JUICE:

i 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

~-~~~~~---1_~~~~~~~------------------------

NO LOW IRON FORMULA ALLOWED

282

! FORMULA: i 15-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

~~~~-----l!:~:.?~~~~!~~~~~-9~~~-~:-~~~--

NO LOW IRON FORMULA ALLOWED

283

! FORMULA: i 16-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

JUICE:

i 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL: i UP TO 24 OZ
------------------------------------------------

NO LOW IRON FORMULA ALLOWED

FP -45

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11 con't

FOOD PACKAGE NUMBER
337
31 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 360ZCEREAL

VOUCHER CODE
282
284

339

284

35 CANS 13 OZ CONCENTRATE FE FORTIFIED LACTOFREE 2 CANS JUICE 360ZCEREAL
286

342

291

9 CANS 14 OZ POWDERED FE FORTIFIED LACTOFREE
375

-"'

066

8 CANS 14 OZ

POWDERED FE FORTIFIED LACTOFREE

375

3 CANS JUICE

240ZCEREAL

375

VOUCHER MESSAGE

FORMULA: JUICE:

I I

15-13 OZ CANS CONCENTRATE IRON

I

I FORTIFIED LACTOFREE

I

I I

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

FORMULA:
JUICE: CEREAL:

!I 16-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE
1 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I UPT0360Z

NO LOW IRON FORMULA ALLOWED

FORMULA:
JUICE: CEREAL:

!I 16-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE
I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN I UPT0360Z

NO LOW IRON FORMULA ALLOWED

! FORMULA: I 19-13 OZ CANS CONCENTRATED IRON FORTIFIED LACTOFREE

JUICE:

I 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

NO LOW IRON FORMULA ALLOWED

! FORMULA I 5-14 OZ CANS POWDERED IRON FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED
! FORMULA: I 4-14 OZ CANS POWDERED IRON FORTIFIED LACTOFREE

NOLOWIRONFORMULAALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS

FORMULA: 4-14 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

FP -46

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11 con't

346
9CANS 140Z POWDERED FE FORTIFIED LACTOFREE 3 CANS JUICE 240ZCEREAL
347
9 CANS 140Z POWDERED FE FORTIFIED LACTOFREE 3 CANS JUICE 360ZCEREAL
381
9 CANS 16 OZ POWDERED PORTAGEN OR PREGESTIMIL 3 CANS JUICE 360ZCEREAL
382 8 CANS 16 OZ POWDER OR 31-13 OZ CANS CONCENTRATE NUTRAMIGEN OR 25 QTS READY-TO-FEED ALIMENTUM

066

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CEREAL:

CANS

UPT0240Z

291

FORMULA: 5-14 OZ CANS POWDERED IRON

FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

375

FORMULA: ~ ~6~~~I~~~~~~~~~D IRON

NO LOW IRON FORMULA ALLOWED

070

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CEREAL:

CANS

UPT0360Z

291

FORMULA: 5-14 OZ CANS POWDERED IRON

FORTIFIED LACTOFREE

NO LOW IRON FORMULA ALLOWED

375

FORMULA: i ~6~~~I~~~~~~~~~D IRON

NO LOW IRON FORMULA ALLOWED

060

FORMULA: 4-1 LB CANS POWDER PORTAGEN OR

PREGESTIMIL

181

FORMULA: 5-1 LB CANS POWDER PORTAGEN OR

PREGESTIMIL

070

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CEREAL:

CANS

UP TO 36 OUNCES

182

FORMULA: 4-1 LB CANS POWDER OR 15-13 OZ

CANS CONCENTRATE NUTRAMIGEN

OR 12 QTS. READY-TO-FEED

ALI MENTUM

183

FORMULA: 4-1 LB CANS POWDER OR 16-13 OZ

CANS CONCENTRATE NUTRAMIGEN

OR 13 QTS. READY-TO-FEED

ALIMENTUM

FP -47

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-11 con't

383 8 CANS 16 OZ POWDER OR 31-13 OZ CANS CONCENTRATE NUTRAMIGEN -OR 25 QTS READY-TO-FEED ALIMENTUM 3 CANS JUICE 240Z CEREAL

182

FORMULA: 4-1 LB CANS POWDER OR 15-13 OZ

CANS CONCENTRATE NUTRAMIGEN

OR 12 QTS. READY-TO-FEED

ALIMENTUM

183

FORMULA: 4-1 LB CANS POWDER OR 16-13 OZ

CANS CONCENTRATE NUTRAMIGEN

OR 13 QTS. READY-TO-FEED

ALI MENTUM

066

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CEREAL:

CANS

UP TO 24 OUNCES

999

999

AS PRESCRIBED

FORMULA IS ORDERED

BY A PHYSICIAN

A TAILORED PACKAGE DESIGNED BY THE CPA

FORMULA EQUALS 8-9

WHICH MUST NOT EXCEED THE MAXIMUM

LBS POWDER OR 9-10, 14

QUANTITY OF SUPPLEMENTAL FOODS FOR THE

OZ POWDER 403-455 OZ

PARTICIPANT'S CATEGORY

CONC. 800-910 OZ RTF;

3-12 OZ FROZEN CANS

360ZCEREAL

FORMULA ONLY MAY BE PRESCRIBED

FP -48

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-12

ALTERNATE FOOD PACKAGES FOR CHILDREN/WOMEN WITH SPECIAL DIETARY NEEDS
Maximum Monthly Amounts

FOOD
Ready-To-Feed Formula

SIZE

MAXIMUM MONTID.Y AMOUNTS

ADDITIONAL AMOUNTS

100-8 oz cans

800 ounces

12-8 oz cans (96 ounces)

Cereal

4-9 ozboxes

36 ounces

Juice

23-6 oz cans

138 ounces

This food package consists of eight (8) vouchers

FP -49

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-13

ALTERNATE FOOD PACKAGES FOR WOMEN AND CHILDREN WITH SPECIAL DIETARY NEEDS

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

370

240 FORMULA: ~ ~~~~~~iA;;::;rc~~~~~i~ IRON

I00 - 8 OZ CANS ENFAMIL ORPROSOBEE

NO LOW IRON FORMULA ALLOWED

4 - 9 OZ BOXES CEREAL 23 - 6 OZ CANS JUICE

240

! FORMULA: I 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

'

NO LOW IRON FORMULA ALLOWED

342

! FORMULA: ! 14-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

NO LOW IRON FORMULA ALLOWED

CEREAL: l 1-9 OZBOX

JUICE:

I 6-6 oz CANS

'

343

! FORMULA: I 14-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

NO LOW IRON FORMULA ALLOWED

CEREAL: I 1-90ZBOX

JUICE:

I 5-6 OZCANS

i ' '

344

! FORMULA: l 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

NO LOW IRON FORMULA ALLOWED

CEREAL: l 1-9 OZBOX

344

! FORMULA: l 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

NO LOW IRON FORMULA ALLOWED

CEREAL l 1-90ZBOX

345

! FORMULA: I 12-8 OZ CANS READY TO FEED ENFAMIL OR PROSOBEE WITH IRON

JUICE:

l 6 -60ZCANS

NO LOW IRON FORMULA ALLOWED
345 FORMULA: ~ ~~~~~iA;;::;~~~~~~IRON

NO LOW IRON FORMULA ALLOWED

JUICE:

I 6-6 OZCANS

FP- 50

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-14

CHILDREN'S FOOD PACKAGES AUTHORIZED MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS

FOOD

MAXIMUM AMOUNT PER MONTH 24 quart equivalents1

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

1 pound bags or 18 ounce jar

1Substitution amounts for fluid milk include:

ITEM

FLUID MILK EQUIVALENTS

Cheese, 1 pound

3 quarts

Evaporate<J 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 of Lactose reduced milk to replace up to 6 gallons of milk.

FP- 51

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-15

CHILDREN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM600 2GAL '.'LK I LB CHEESE I DOZEGGS 18 OZ CEREAL 4CANSJUICE
MINIMUM601 4GALSMILK I DOZEGGS 4 CANS JUICE 240ZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
......

VOUCHER CODE 042 040 039
049 040 039
040 037

VOUCHER MESSAGE

CHEESE: JUICE:

UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK: JUICE

I GAL OR 4-12 OZ CNS EVAP OR 1-5 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK:
EGGS: JUICE:

1 GAL OR 4-12 OZ CNS EVAP OR 1-5 QTBOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

JUICE: CEREAL:

i-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 18 OUNCES

MILK: JUICE:

I GAL OR4-12 OZ CNS EVAP OR 1-5QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK:
EGGS: JUICE:

I GAL OR 4-12 OZ CNS EVAP OR 1-5 QTBOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK:

l 1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX

JUICE:

1 1-12 OZ CAN p;:. ZEN OR 1-46 OZ CAN

CEREAL:

I UPT0240W ::,

BEANS/PEAS I I LB DRIED BLANS/PEAS OR

I PEANUT BUTTER:

I

I

I I

18 OZ PEANUT BUTTER

I

I

FP- 52

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-15 con't

FOOD PACKAGE NUMBER 602
LIMITED MILK LACTOSE INTOLERANT
2GALSMILK 2 LBS CHEESE 2DOZEGGS 4 CANS JUICE 240ZCEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MODERATE 603* 4GALSMILK 1 LB CHEESE 2DOZENEGGS 4CANS JUICE 240ZCEREAL I LB BEANS/PEAS
* STANDARD MANUAL

VOUCHER CODE
042

CHEESE: JUICE:

VOUCHER MESSAGE
UPTO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

043

CHEESE: JUICE: BEANS/PEAS I

UPTO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN 1 LB DRIED BEANS/PEAS OR

PEANUT BUTTER:

1 18 OZ PEANUT BUTTER

048

MILK:

1 GALOR4-120ZCANSEVAP

EGGS: JUICE:

OR 1-5 QTBOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

039

MILK:

EGGS: JUICE:

1 GAL OR4-12 OZ CANS EVAP OR 1-5 QTBOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

047

MILK:

1 GAL OR 4-12 OZ CANS EVAP

OR 1-5 QTBOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

039

MILK:

EGGS: JUICE:

1 GAL OR4-12 OZ CANS EVAP OR 1-5 QTBOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

025

MILK:

I GAL OR4-12 OZ CANS EVAP

OR 1-5 QT BOX

CHEESE:

UPTO 1 LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

BEANS/PEAS 1 LB DRIED BEANS/PEAS

039

MILK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

FP-53

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '9"7

Attachment FP-15 con't

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

604

031

MILK:

I GALOR4-120ZCANSEVAP

OR 1-5 QTBOX

4GALSMILK

CHEESE:

UPTO I LB

2LBSCHEESE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

2DOZENEGGS

4 CANS JUICE

037

MILK:

I GAL OR4-12 OZ CANS EVAP

240ZCEREAL

OR 1-5 QTBOX

I LB DRIED BEANS/PEAS

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

ORI80ZPEANUTBUTTER

CEREAL:

UP TO 24 OUNCES

BEANS/PEAS/ I LB DRIED BEANS/PEAS OR

PEANUT

BUTTER:

18 OZ PEANUT BUTTER

039

MILK:

EGGS: JUICE:

I GALOR4-12 OZ CANS EVAP OR 1-5 QTBOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

055

MILK:

CHEESE: EGGS: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX UPTO I LB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

605
LACTOSE REDUCED MILK LACTOSE INTOLERANT 16 QTS LACTOSE REDUCED MILK 2LBSCHEESE 2DOZEGGS 6CANSJUICE 240ZCEREAL I LB BEANS/PEAS OR 18 OZ JAR PEANUT BUTTER

044

MILK:

CHEESE: JUICE: CEREAL:

4 QTS OR 2-112 GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 24 OUNCES

034

MILK:

EGGS: JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE I DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CAN

045

MILK:

4 QTS OR 2-1/2 GAL ACIDOPHILUS

ENJOY, LACTAID, LACTAID 100,

NUTRISH, DAIRY EASE

CHEESE:

UPTO I LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

BEANS/PEAS/ 1 I LB DRIED BEANS/PEAS OR PEANUT

BUTTER:

18 OZ PEANUT BUTTER

034

MILK:

EGGS: JUICE:

4 QTS OR 2-112 GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE I DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CAN

FP-54

REVISED 09/%

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP -15 con't

FOOD PACKAGE NUMBER 606
4 GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MAXIMUM 607 6 GALS MILK 2 DOZEN EGGS 6 CANS JUICE 360Z CEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE

VOUCHER MESSAGE

028

MILK:

EGGS: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX I DOZEN 1-12 OZ CANS FROZEN OR 2-46 OZ CANS

031

MILK:

CHEESE: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO I LB 1-12 OZ CANS FROZEN OR 1-46 OZ CAN

054

MILK:

CHEESE: EGGS: JUICE:

I GAL OR 4-12 OZ CANS EV AP OR 1-5 QT BOX 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 EVAP OR
I
1-5 QTBOX

JUICE:

2-12 OZ CANS FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 36 OUNCES

BEANS/PEAS/

I LB DRIED BEANS/PEAS OR

P'NUT

18 OZ PEANUT BUTTER

BUTTER:

027

MILK:

2 GAL OR 8-12 OZ CANS EVAP OR

2-3 QTS

JUICE:

1-12 OZ CANS FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 36 OUNCES

BEANS/PEAS/

I LB DRIED BEANS/PEAS OR

P'NUT

18 OZ PEANUT BUTTER

BUTTER:

028

MILK:

EGGS: JUICE:

I GAL OR 4-12 OZ CANS EV AP OR 1-5 QT BOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

032

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOXES I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

046

MILK:

JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CANS FROZEN OR 1-46 OZ CANS

FP-55

REVISED 09/96

GA WI PROCEDURES MANUAL FFY '97

Attachment FP-15

999*

999

!AS PRESCRIBED

6 GALS OR 24 QTS MILK

A TAILOREDPACKAGE DESIGNED BY THE CPA WHICH

4 LBS CHEESE

MUST NOT EXCEED THE MAXIMUM QUANTITY OF

2 DOZEN EGGS

SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S

6 CANS JUICE

CATEGORY.

36 OZ CEREAL

I LB BEANS/PEAS OR

18 OZ PEANUT BUTTER

* A maximum of 2 pounds of cheese per month is recommended except for those with lactose intolerance

FP-56

REVISED 09/96

GA WI PROCEDURES MANUAL FFY '97

Attachment FP-16

ALTERNATE FOOD PACKAGES FOR CHILDREN 1-5 YEARS

Maximum Monthly Amounts

FOOD UHTMilk
Lactose Reduced Milk

SIZE

MAXIMUM AMOUNTS

96-8 oz boxes

768 ounces

OR

22 quarts or 11 - ~ gallons 704 ounces

Cereal Juice Peanut Butter

4-9 oz boxes 42-6 oz cans 2-18 ozjars

36 ounces 252 ounces 36 ounces

This food package consist of eight (8) vouchers.

FP-57

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-17

ALTERNATE FOOD PACKAGES FOR CHILDREN 1-5 YEARS

FOOD PACKAGE NUMBER
' 610
97- 8 OZ BOXES UHT MILK OR
22 QTS OR II - Yz GALLONS LACTOSE REDUCED MILK 4-9 BOXES CEREAL 42-6 OZ CANS JUICE 2-18 OZ JARS PEANUT BUTTER

VOUCHER CODE 610
611 611 611 612
6I3 6I4
6I5

VOUCHER MESSAGE

MILK:
CEREAL: JUICE: PEANUT BUTTER:
MILK:
JUICE:

12-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED I-90ZBOX 6-60Z CANS
1-18 OZJAR
---~"
12-8 OZ BOXES UHT OR 2 "-; ,, OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZ CANS

MILK: JUICE:

12-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZCANS

MILK: JUICE:

12-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZ CANS

MILK:
CEREAL: JUICE:

I2-8 OZ BOXES UHT OR 2 QTS OR I-I/2 GAL LACTOSE REDUCED I-90ZBOX 6-60ZCANS

MILK: CEREAL:

I2-8 OZ BOXES UHT OR 2 QTS OR I - Yz GAL LACTOSE REDUCED I -90ZBOX

MILK:
CEREAL: JUICE:

I2- 8 OZBOXES UHTOR4 QTS OR2- Yz t GAL LACTOSE REDUCED
I -90ZBOX 6-60ZCANS

MILK:
PEANUT BUTTER: JUICE:

I2-8 OZ BOXES UHT OR 4 QTS OR 2 - Yz GAL LACTOSE REDUCED
I-I8 OZ JAR 6-6 OZCANS

FP-58

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-18

WOMEN'S FOOD PACKAGES AUTHORIZED MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS

FOOD
Milk Cheese Eggs Juice
Cereal Dried Beans/Peas or Peanut Butter

PREGNANT, BREASTFEEDING AND NON-BREASTFEEDING

28

quart

equivalents

23 '

4 pounds 4

2 dozen

6-46 oz cans or 6-12 oz cans frozen

36 ounces

1 pound bag or 1-18 ozjar

Carrots 5

Tuna 5

-----------

1 Substitution amounts for fluids milk include:

EXCLUSIVELY BREASTFEEDING 5
28 quart equivalents 1 pound 2 dozen 7-46 oz cans or 7-12 oz cans frozen 36 ounces 1 lb. bag or 18 oz jar plus an additional 1 lb. bag 2 pounds, fresh, whole 4-6 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 monthly milk allotment. A maximum oftwo (2) pounds of cheese per month is recommended

except for those with lactose intolerance.

3

Substitute up

to

28

quarts

of reduced milk for up

to

7 gallons

of milk

4

Substitute

up

to

4

lbs

cheese

for

up

to

7

gallons

of milk.

5

Additional items

authorized for

exclusively breastfeeding women

only.

FP-59

REVISED 09196

GA PROCEDURES MANUAL FFY '97

Attachment FP-19

PREGNANT AND BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE

'

NUMBER

MINIMUM40I

4GALSMILK I DOZEGGS 4 CANS JUICE 240ZCEREAL I LB BEANS/PEAS OR I8 OZ PEANUT BUTTER

VOUCHER CODE

040

MILK:

JUICE:

039

MILK:

EGGS: JUICE:

037

MILK:

.I
040

JUICE: CEREAL: BEANS/PEAS/ P'NUT BUTTER:
MILK:

JUICE:

VOUCHER MESSAGE
I GAL OR 4-I2 OZ CANS EVAP OR I-5 QTBOX I-12 OZ CAN FROZEN OR I-46 OZ CAN
I GAL OR4-12 OZ CANS EVAP OR I-5 QTBOX I DOZEN I-I2 OZ CAN FROZEN OR I-46 OZ CAN
I GAL OR 4-12 OZ CANS EVAP OR I-5 QTBOX I-I2 OZ CAN FROZEN OR I-46 OZ CAN UP TO 24 OUNCES I LB DRIED BEANS/PEAS OR I8 OZ PEANUT BUTTER
I GAL OR 4-12 OZ CANS EVAP OR I-5 QTBOX I-I2 OZ CAN FROZEN OR I-46 OZ CAN

402 LIMITED MILK LACTOSE INTOLERANT
2GALSMILK 2LBSCHEESE 2DOZEGGS 6 CANS JUICE 360ZCEREAL I LB BEANS/PEAS OR I8 OZ PEANUT BUTTER

04I

MILK:

EGGS: CEREAL: JUICE:

042

CHEESE:

JUICE:

I GAL OR 4-12 OZ CANS EVAP OR I-5QTBOX I 1 DOZEN 2-I2 OZ CANS FROZEN OR 2-46 OZ CANS UP TO 36 OU?-5CES
. .,.,
UPTO I LB I-I2 OZ CAN FROZEN OR I-46 OZ CAN

028

MILK:

EGGS: JUICE:

I GAL OR4-12 OZ CANS EVAP OR I-5QTBOX I DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ ; CANS

043

CHEESE:

I I

UPTO l LB

I

JUICE:

I l-12 OZ CAN FROZEN OR I-46 OZ CAN

I

BEANS/PEAS/

I I

I LB DRIED BEANS/PEAS OR

P'NUT

I I

I8 OZ PEANUT BUTTER

BUTTER:

I I

FP-60

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-19 con't

FOOD PACKAGE NUMBER
MODERATE 403 4GALSMILK I LBCHEESE I DOZEGGS 4 CANS JUICE 240ZCEREAL I LB BEANS/PEAS OR I 8 OZ PEANUT BUTTER
404* 4GALSMILK 2LBSCHEESE 2DOZEGGS 6 CANS JUICE 240ZCEREAL I LB BEANS/PEAS OR I 8 OZ PEANUT BUTTER
*STANDARD MANUAL

VOUCHER CODE
037

MILK:
JUICE: CEREAL: BEANS/PEAS/ P'NUT BUTTER:

VOUCHER MESSAGE
l I GALOR4-I20ZCANSEVAPOR
I-5 QTBOX I- I2 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 24 OUNCES I LB DRIED BEANS/PEAS OR I 8 OZ PEANUT BUTTER

039

MILK:

EGGS: JUICE

I GAL OR4-I2 OZ CANS EVAP OR I-5 QTBOX I DOZEN I-I2 OZ CAN FROZEN OR I-46 OZ CAN

031

MILK:

CHEESE: JUICE:

I GAL OR4-I2 OZ CANS EVAP OR 1-5 QTBOX UPTO I LB I-12 OZ CAN FROZEN OR 1-46 OZ CAN

040

MILK:

JUICE:

t I GALOR4-I20ZCANSEVAPOR I-5 QTBOX I-I2 OZ CAN FROZEN OR 1-46 OZ CAN

028

MILK:

EGGS: JUICE:

I GALOR4-I2 OZ CANS EVAP OR 1-5 QTBOX I DOZEN 2- I2 OZ CANS FROZEN OR 2-46 OZ CANS

03I

MILK:

CHEESE: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR I-5 QTBOX UPTO I LB I-I2 OZ CAN FROZEN OR I-46 OZ CAN

037

MILK:

I GAL OR 4-I2 OZ CANS EVAP OR

I-5 QTBOX

JUICE:

1-12 OZ CAN FROZEN OR I-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

BEANS/PEAS/ I LB DRIED BEANS/PEAS OR

P'NUT

I 8 OZ PEANUT BUTTER

BUTTER:

054

MILK:

CHEESE: EGGS: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX UPTO I LB I DOZEN 2-I2 OZ CAN FROZEN OR 2-46 OZ CAN

FP-61

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-19 con't

FOOD PACKAGE NUMBER
405
LACTOSE REDUCED MILK
LACTOSE INTOLERANT
12 Q"; LACTOSE REDF:-:ED MILK 3 LBS CHEESE 2DOZEGGS 6 CANS JUICE 360ZCEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE

033

MILK:

CHEESE: JUICE: CEREAL:
MILK: 034
EGGS: JUICE:

035

MILK:

CHEESE: JUICE: BEANS/PEAS/ P'NUT BUTTER:

036

MILK:

CHEESE: EGGS: JUICE:
'""' .,.

VOUCHER MESSAGE
4 QTS OR 2-1/2 GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE UPTO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 36 OUNCES
4 QTS OR 2-1/2 GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS
2 QTS OR Y, GAL ACIDOPHILUS ENJOY, LACTAID, LACTAID 100, NUTRISH, DAIRY EASE UPTO 1 LB 2-12 OZ CANS FROZEN OR 2-46 OZ CANS 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
2 QTS OR Y, GAL ACIDOPHILUS, ENJOY, LADTAID, LACTAID 100, NUTRISH, DAIRY EASE UPTO 1 LB 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

FP-62

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-19 con't

FOOD PACKAGE NUMBER 406
5 GALS MILK 2 LBS CHEESE 2DOZENEGGS 6 CANS JUICE 36 OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MAXIMUM407 7GALSMILK 2DOZENEGGS 6 CANS JUICE 360ZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE

027

MILK:

JUICE: CEREAL: BEANS/PEAS/ P'NUT BUTTER:

028

MILK:

EGGS: JUICE

031

MILK:

CHEESE: JUICE:

054

MILK:

CHEESE: EGGS: JUICE:

027

MILK:

JUICE: CEREAL: BEANS/PEAS/ P'NUT BUTTER:

028

MILK:

EGGS: JUICE:

029

MILK:

JUICE:

030

MILK:

EGGS: JUICE:

VOUCHER MESSAGE
2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 36 OUNCES I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
I GAL OR4-12 OZ CANS EVAP OR 1-5 QTBOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS
I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I GALOR4-120ZCANSEVAPOR 1-5 QTBOX UPTO I LB I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CAN
2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 36 OUNCES I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
I GALOR4-120ZCANSEVAPOR 1-5 QTBOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS
2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QTBOXES 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QTBOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

FP-63

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-19 con't

FOOD PACKAGE NUMBER
408* EXCLUSIVELY BREASTFEEDING
7GALSMILK I LB CHEESE 2DOZENEGGS 7 CANS JUICE 360ZCEREAL 1 LB BEANS/PEAS OR 1-18 OZ PEANUT BUTTER PLUS 1 LB BEANS/PEAS 2 LBS CARROTS 4CANSTUNA

VOUCHER CODE
001

CHEESE: JUICE: CARROTS: TUNA: BEANS/PEAS:

027

MILK:

JUICE: CEREAL: BEANS/PEAS/ P'NUT BUTTER:

028

MILK:

EGGS: JUICE:

029

MILK:

JUICE:

VOUCHER MESSAGE
UPTO I LB 1-12 OZ FROZEN OR 1-46 OZ CAN 2-1 LB SEALED PLASTIC BAGS 4-6 OZCANS I LB DRIED BEANS OR PEAS
2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 36 OUNCES 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS
2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QTBOXES 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

999
7 GALS OR 28 QTS MILK 4LBSCHEESE 2DOZEGGS 7CANSJUICE 360ZCEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

030

MILK:

, FGGS: iCE:
"

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QTBOXES I DOZEN 2-12 OZ 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 PARTICIPANT'S 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 the maximum amounts listed in package 408.
b. Substitution for food package 408 only: 1. 5 gallons of milk and 2 lbs. cheese to replace 7 gallons of milk 2. 4lbs cheese to replace 7 gallons of milk
**c. A maximum of 2 pounds of cheese per month is recommended except for those with lactose intolerance.

FP-64

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP - 20

ALTERNATEFOODPACKAGESFORPREGNANTAND BREASTFEEDING WOMEN
Maximum Monthly Amounts

FOOD
UHTMilk

PREGNANT, AND BREASTFEEDING
112-8 oz boxes

EXCLUSIVELY BREASTFEEDING
124- 8 oz boxes

Lactose Reduced Milk

OR
16 quarts or 8 - Y2 gallons

31 quarts or 15 - Y2 gallons

Cereal

4-9 oz boxes

4-9 oz boxes

Juice

42- 6 oz cans

56-6 oz cans

Peanut Butter

2-18 ozjars

Beans/Peas

Tuna

Carrots

This food package consists of 8-9 vouchers

3-18 ozjars 4-15 oz cans 6-6 oz cans 2-15 oz cans only

FP-65

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-21

ALTERNATE FOOD PACKAGES FOR PREGNANT AND BREASTFEEDING WOMEN

FOOD PACKAGE

'

NUMBER

410 (PREGNANT& BREASTFEEDING)

II2- 8 OZ BOXES UHT MILK OR I6 QTOR 8 - Y, GAL LACTOSE REDUCED MILK 4-9 OZ BOXES CEREAL 42-6 OZ CANS JUICE 2-I8 OZ JARS PEANUT BUTTER

VOUCHER CODE
620

MILK:

CEREAL: JUICE: PEANUT BUTTER:

62I

MILK:

JUICE:

62I

MILK:

JUICE:

62I

MILK:

JUICE:

622

MILK:

CEREAL: JUICE:

622

MILK:

CEREAL: JUICE:

623

MILK:

CEREAL:

624

MILK:

JUICE: PEANUT BUTTER:

VOUCHER MESSAGE
I4-8 OZ BOXES UHT OR 2 QTS OR I-112 GAL LACTOSE REDUCED I-90ZBOX 6-60Z CANS
I-18 OZJAR
I4-8 OZ BOXES UHT OR 2 QTS OR I-112 GAL LACTOSE REDUCED 6-6 OZ CANS
14-8 OZ BOXES UHT OR2 QTS OR I-I/2 GAL LACTOSE REDUCED 6-6 OZCANS
I4-8 OZ BOXES UHT OR 2 QTS OR I - Y, GAL LACTOSE REDUCED 6-6 OZ CANS
I4-8 OZBOXES UHTOR2 QTS OR I-1/2 GAL LACTOSE REDUCED 1-9 OZBOX 6-6 OZCANS
I4-8 OZ BOXES UHT OR 2 QTS OR I - y, GAL LACTOSE REDUCED I-9 OZBOX 6-60ZCANS
I4- 8 OZ BOXES UHTOR2 QTS OR I- Y, GAL LACTOSE REDUCED I-90ZBOX
I4-8 OZ BOXES UHT OR 2 QTS OR I- y, GAL LACTOSE REDUCED 6-6 OZCANS
I-I8 OZ JAR

FP-66

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-21 con't

FOOD PACKAGE NUMBER

VOUCHER CODE

411

630

MILK:

(EXCLUSIVELY

BREAST FEEDING)

CEREAL:

JUICE:

124-8 OZ BOXES UHT MILK

P'NUT

31 QUARTS OR 15-1/2 GAL

BUTTER:

LACTOSE REDUCED MILK

BEANS/ PEAS:

36 OZCEREAL

CARROTS:

56-6 OZ CANS JUICE 3-18 OZ JAR PEANUT

631

MILK:

BUTTER 6-6 OZ CANS TUNA 4-15 OZ CANS BEANS/PEAS

JUICE: TUNA:

2-15 OZ CANS CARROTS

631

MILK:

JUICE: TUNA:

632

MILK:

CEREAL: JUICE: P'NUT BUTTER:

634

MILK:

JUICE: P'NUT BUTTER:

635

MILK:

CEREAL: JUICE: BEANS/ PEAS: CARROTS:

VOUCHER MESSAGE
15-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 7-6 OZ CANS 1-180ZJAR 1-15 OZ CAN 1-15 OZ CAN
15-8 OZ BOXES UHT OR 4 QTS OR 2-112 GAL LACTOSE REDUCED 7-6 OZCANS 2-6 OZCANS
15-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED 7-6 OZCANS 2-6 OZCANS
15-8 OZ BOXES UHT OR 4 QTS OR 2-112 GAL LACTOSE REDUCED 1-90ZBOX 7-6 OZCANS 1-18 OZJAR
15-8 OZ BOXES UHT OR 4 QTS OR 2-112 GAL LACTOSE REDUCED 7-6 OZ CANS 1-18 OZ JAR
15-8 OZ BOXES UHT OR 4 QTS OR 2-112 GAL LACTOSE REDUCED 1-90ZBOX 7-60ZCANS 1-15 OZCAN 1-15 OZ CAN

636

MILK:

19-8 OZ BOXES UHT OR 4 QTS OR 2-1/2

GAL LACTOSE REDUCED

JUICE:

7-6 OZCANS

BEANS/ PEAS: 1-15 OZCAN

CEREAL:

1-90ZBOX

633

MILK:

15-8 OZ BOXES UHT OR 3 QTS OR 1-112

GAL LACTOSE REDUCED

JUICE:

7-6 OZCANS

BEANS/ PEAS: 1-15 OZ CAN

TUNA:

2-6 OZ CANS

FP-67

REVISED 09196

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-23

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES AUTHORIZED MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS

FOOD

MAXIMUM AMOUNT PER MONTH 24 quart equivalents1

Cheese

4 pounds2

Eggs

2 dozen

Juice

4-46 oz cans or 4-12 oz frozen

Cereal

36 ounces

1 Substitution amounts for fluid milk include:

ITEM

FLUID MILK EQIJIVAI,ENTS

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 oflach:-.,~ reduced milk to replace up to 6 gallons of milk.

FP-68

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-23

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM501 3 GALS MILK I DOZEN EGGS 3 CANS JUICE 18 OZ CEREAL
502 * 3 GALS MILK 2LBSCHEESE I DOZEGGS 4 CANS JUICE 240ZCEREAL
*STANDARD MANUAL

VOUCHER CODE
040

MILK:

JUICE

040

MILK:

JUICE:

053

MILK:

CEREAL:

052

JUICE:

EGGS:

040

MILK:

JUICE:

042

CHEESE:

JUICE

047

MILK:

JUICE: CEREAL:

055

MILK:

CHEESE: EGGS: JUICE:

VOUCHER MESSAGE
I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I GAL OR4-12 OZ CANS EVAP OR 1-5 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I GAL OR4-12 OZ CANS EVAP OR 1-5 QTBOX UP TO 18 OUNCES
1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I
I DOZEN
I GAL OR4-12 OZ CANS EVAP OR 1-5 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN UP TO 24 OUNCES
I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX UPTO I LB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

FP-69

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97 .

Attachment FP-23 con't

FOOD PACKAGE NUMBER
MAXIMUM503 6 GALS MILK 2DOZENEGGS 4 CANS JUICE 360ZCEREAL
504 LACTOSE REDUCED MILK LACTO:::: INTOLERANT 12QTSM1LK 2LBSCHEESE I DOZEN EGGS 4CANSJUICE 240ZCEREAL
999* 6 GALS OR 24 QTS MILK SUBSTITUTE 1 LB CHEESE FOR 3 QTS MILK 2DOZENEGGS 4 CANS JUICE 360ZCEREAL

VOUCHER CODE

VOUCHER MESSAGE

050

MILK:

I GAL OR4-12 OZ CANS EVAP OR

1-5 QTBOX

EGGS:

I DOZEN

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 36 OUNCES

051

MILK:

2 GALS OR 8-12 OZ CANS EVAP OR

I 2-5 QTBOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

039

MILK:

EGGS: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QTBOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

051

MILK:

1 2 GALS OR 8-12 OZ CANS EVAP OR

2-5 QTBOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

501

MILK:

4 QTS OR 2-1/2 GAL ACIDOPHILUS,

ENJOY LACTAID, LACTAID 100,

NUTRISH, DAIRY EASE

CHEESE:

UPTO 1 LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

502

MILK:

EGGS: JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS, ENJOY LACTAID, LACTAID 100, NUTRISH, DAIRY EASE I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

503

MILK:

2 QTS OR 1-1/2 GAL ACIDOPHILUS,

ENJOY, LACTAID, LACTAID 100,

NUTRISH,DAIRYEASE

CHEESE:

UPTO 1 LB

JUICE:

1-12 OZ FROZEN OR 1-46 OZ CAN

504

MILK:

2 QTS OR 1-1/2 GAL ACIDOPHILUS,

ENJOY, LACTAID, LACTAID 100,

NUTRISH, DAIRYEASE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

UP TO 24 OUNCES

999

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY

* A maximum of 2 pounds of cheese per month is recommended except for those with lactose
intolerance

FP-70

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-23

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

1-18 ozjar

This food package consists of eight (8) vouchers.

MAXIMUM AMOUNT 576 ounces
36 ounces 184 ounces 18 ounces

FP-71

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-24

ALTERNATE FOOD PACKAGES FOR POSTPARTUM, NON-BREASTFEEDING WOMEN

FOOD PACKAGE NUMBER
510
72 - 8 OZ BOXES UHT MILK 18 QTS OR 9-112 GAL LACTOSE REDUCED MILK 4-9 OZ BOXES CEREAL 30-6 OZ CANS JUICE 1-18 OZ JAR PEANUT BUTTER

VOUCHER CODE

642

MILK:

CEREAL: JUICE:

645

MILK:

PEANUT BUTTER: JUICE

642

MILK:

CEREAL: JUICE:

641

MILK:

642

MILK:

CEREAL: JUICE:

641

MILK:

641

MILK:

642

MILK:

CEREAL: JUICE:

VOUCHER MESSAGE
!: 9-8 OZ BOXES UHT OR 2 QTS OR 1-112 GAL LACTOSE REDUCED ~ 1-9 OZBOX
c;-60ZCANS
9-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED
1-18 OZ JAR 6-6 OZCANS
9-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-90ZBOX 6-6 OZ CANS
9-8 OZ BOXES UHT OR 2 QTS OR 1-112 GAL LACTOSE REDUCED
:9-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-90ZBOX 6-60Z CANS
9-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED
! 9-8 OZ BOXES UHT OR 2 QTS OR 1-112 GAL LACTOSE REDUCED
!: :9-R OZ BOXES UHT OR 2 QTS OR 1-112 G/.......ACTOSE REDUCED : 1-v. OZ BOX : 6-60ZCANS

FP-72

REV,ISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-26

GEORGIA WIC FORMULA REFERRAL FORM* (To Be Completed By Referral Agency)

DATE:

TO:

------------------------ WICPROGRAM

FROM:

Signature!fitle (Physician)

------------------------ Health Facility - Location
PHONE#:

1.

is a resident of

------------~~~A~M~E)~------------------

-----~(C~O~UN~T~Y~)-------

He/She receives treatment for------,-------.,..,.,-,--------- His/Her local physician

is

(DIAGNOSIS)

--------=-::-:-:-~-------- Please provide ----,,..,.-,~=:--ounces of-::-:,.,..,.-=:---

~AME)

(AMOUNT)

~AME)

formula monthly. I estimate he/she will need this formula for

months.

~UMBER)

2. Check the correct statement:

0 This client has been assessed for the WIC Program. A WIC Program Assessment/Certification is
attached.

0 Please assess this client for the WIC Program. The following information was collected on

Length/Height* _ _ __

Weight* _ _ __

Hematocrit/Hemoglobin** _______

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: Infants- 4 months old up to 92 ounces of fruit juice and 24 ounces of infant cereal. Children - up to 4 quarts of fruit juice and 36 ounces of cereal.

* Sample Form. May be adapted for local agency use. ** Please include this information, if available.
FP-73

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-26 con't

GEORGIA WIC APPROVED FOOD LIST CRITERIA TO EVALUATE AN ELIGffiLE FOOD ITEM
I. Administrative Adjustments

A. A food company interested in participating in the Georgia WIC Program should submit product statewide availability, package size, unit cost per ounce and nutrient composition information to the Office of Nutrition* by October 1st of each year.

B. A review of potentially new food items shall be conducted biennially.** Consequently, the WIC Approved Food List shall be printed biennially only.

C. A product must be commercially available as a brand name, or a store brand for a minimum of twelve (12) consecutive months prior to October 1st of each year.

D. The food item cost cannot exceed 10 percent (10%) of the State average cost per ounce for that food group. Food groups include:

1. Milk 2. Eggs 3. Cereal 4. Infant Cereal 5. Tuna

6. Cheese 7. Juice 8. Dried Beans/Peas and Peanut Butter 9. Carrots

E. Food item must be acceptable to participants.

II. Nutrition Quality

A. Cereal - Adult

1. Contains a minimum of 28 mg. of iron per 100 gm. of dry cereal. 2: Contains not more than 14.1 gm. of sucrose and other sugars per 100 gm. of dry cereal (less
than 4 gm. per ounce). High fiber cereals (5 gm or more) must not contain more than 6 gm. of total sugar per 100 gm. of d: ' cereal. 3. Contains not more than 500 :c<. of sodium per 1 ounce of dry cereal. 4. Contains no artificial or non-nutritive sweeteners.

B. Cereal- Infant 1. Contains a minimum of 45 mg. of iron per 100 gm. of dry cereal. 2. Contains no added sugar. 3. Contains no added fruit. 4. Contains no added formula

C. Milk 1. Contains 400 IU vitamin D per quart. 2. Contains 2,000 IU vitamin A per quart. 3. Contains no added sugar or flavorings. 4. No Buttermilk or Goat's milk.

D. Cheese 1. Domestic Cheese (pasteurized, processed American, Monterey Jack, Colby, Natural Cheddar, Mozzarella).

E. Peanut Butter and Canned! Dried Beans and Peas

FP-74

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-26 con't

1. Including, but not limited to: black, navy, kidney, garbanzo, soy, pinto and mung beans; crowder, cow, split and blackeyed peas; lentils.
2. No flavored beans/peas allowed. 3. No peanut butter and jelly or honey combinations.

F. Juice

1. Single strength or frozen concentrate 100% fruit juice.

2. 30 mg. vitamin C per 100 mi. of reconstituted juice, minimum.

3. Contains no added sugar



4. Contains no added calcium

5. No infant juices allowed

G. Eggs 1. Whole, large, grade A.

H. Carrots 1. Mature, raw or canned, packaged in water only.

I. Tuna 1. 100% tuna, water packed only.

III. Packaging

A. Food must be prepackaged, no bins.

B. Cereal (adult and infant) 1. No single serving containers. 2. Adult cereal weight must be in whole numbers, minimum of9 ounces, not to exceed 36 ounces. 3. Infant cereal only in eight (8) ounce packages.

C. Cheese 1. Brick or sliced cheese only, no shredded. 2. Cheese from the dairy case only, no deli cheese. 3. Plain cheese only, no additions of products such as jalapeno peppers. 4. A minimum of9 ounces, not to exceed 16 ounces.

D. Juice 1. No single serving containers. 2. No fresh squeezed. 3. Containers must be easily and clearly identified as fortified with 30 mg. of vitamin C per 100 mi. ofjuice, except orange juice and grapefruit juice. 4. Forty-six (46) ounce cans 12 ounce frozen cans or 6 ounce can only.

E. Eggs 1. One dozen size carton only.

F. Milk 1. One gallon size only for Whole, Skim, 99% Fat Free (1 %), Fat Free(~%) Lowfat (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. 5. 8 ounce box for ultra high temperature (UHT) milk.

FP-75

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-26 con't

G. Carrots 1. One pound plastic bag, pre-packaged with wire or adhesive tape or 15 ounce can only.
H. Tuna 1. 6 ounce can only.
I. Peanut Butter 1. 18 ounce jar only.
J. Dried Beans/Peas 1. 1 pound bag or 15 ounce can only.
IV. Formula
A. Complete Formula 1. Iron fortified infant formula which contains at least 10 mg. iron per liter of formula at standard dilution. 2. 67 kcal. per milliliter (approximately 20 kcal. per fluid ounce at standard dilution).
B. Formula Not Meeting the Requirements for a Complete Formula 1. Formula intended for use as an oral feeding and prescribed by a physician when the participant has a medical condition which precludes the use of conventional formula or food. 2. Allow supplements to be used in conjunction with an appropriate prorated food package. Substitute a specified amount of supplement per quart or can of milk or formula.

"'

Address: Georgia Division of Public Health, Office of Nutrition, 2 Peachtree Street, NW, Suite 8-413, Atlanta, Georgia 30303

"'"' Biennial review of the WIC Food List does not necessarily constitute a change in the food list. Changes to the WIC
Approved Food List shall occur more frequently only to accommodate Federal mandates.07/94

FP-76

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-27

FOOD ITEM
MILK
(Pasteurized)
CEREAL

Georgia WIC Program WIC APPROVED FOOD LIST

BRAND OR TYPE

ONLYthe fioIIowmg 1stoffoods rna be~ purehased usmg WIC vouc ers: CONTAINER/PACKAGE SIZE

NOT ALLOWED

Whole, Skim, 99% Fat Free, or Low Fat (2%) (Least Expensive Brand ONLY)
Acidophilus, Enjoy, Lactaid, Lactaid I00, Daily Ease or Nutrish
(Evaporated or Powder)

One( I) Gallon Size ONLY (Exception: y, Gallons or Quarts of Enjoy, Lactaid, Lactaid 100, Dairy Ease, Nutrish and/or Acidophilus,
12-0unce Cans Evaporated, 3-5 Quart Boxes Powdered

Floaroed Milk, Buttermilk, or Goat's Milk

Cheerios, Chex-Com,- ( Rice or Wheat) Crispy Critters, Country Com Flakes
Kix, Nabisco Cream ofWheat(Regular Flavor), Product 19, Jim Dandy Quick Grits (Iron Fortified), Minute 3
Brand Instant Oatmeal (Regular Flavor), Quaker Instant Grits (Regular Flavor), Total (Corn), Kellogg's Special K,
Kelloggs's Corn Flakes, Kellogg's Complete Bran Flakes, Quaker Sun Country Quick Oats (Regular Flavor), Quaker Crunchy Corn Bran,
*{Ralston Optima 100 Whole Wheat Flakes, Ralston Enriched Bran Flakes, Ralston Nutty Nuggets, Ralston Instant Oatmeal (Regular Flavor), Ralston : Crispy Rice, Ralston Corn Flakes, Ralston Tasteeo,Ralston Crispy
Corn Pu.DJ *Store Brands Allowed: Kroger, Kounty Fresh, IGA, Red
& White, Flavorite or Nature's .Best

Nine(9) Ounce Sizes and Above ONLY
Can Purchase More Than One(l) Type/Brand of Cereal As Long As
The Amount Does Not Go Over The Quantity on the Front of The
Voucher

Eight(8) Ounces or Less Size Boxes

CHEESE

American (Sliced, Singly Wrapped or Block), Cheddar (Block, Colby (Block), Monterey Jack (Block), Mozzarella (Block),

JUICE
(100% USRDA Vitamin C Fortified)

ORANGE (Least Expensive Brand ONLY)
GRAPEFRUIT (Least Expensive Brand ONLY)
GRAPE (Welch's or Juicy Juice)
WHITE GRAPE (Welch's, Seneca)
APPLE (Flavoritc, Kroger, Lucky Leaf, Juicy Juice, Seneca {Red Label Only}, Staff, Thifty Maid, ShurFine, White House), OTHER (Dole: Orange/Pineapple, Orange/Pineapple/Banana,
Pineapple/Grapcfrui~Pineapplc!Passionlllanana,Pineapple/Orangel
Guava,Mandarin Tangerine, Mountain Chcny, Orcbard Peach, CountJy Raspberry, Tropical Frui~ Juicy Juice: Chcny, Punch, Tropical, Bcny, Apple/Grape, Orange/ Punch, Sttawbcny

Nine(9) Ounce, Up to I 6-0unce [One (I) Pound] size ONLY
46-0unce Cans or I2-0unce Frozen Cans ONLY

Cheese Food, Shredded or Dell Cheese, Two (2) Eight (8)
Ounce Packages for One( I) 16-0unce Package, or any eight (8) Ounce or smaller
package
Juice Drinks, Fresh Squeezed Juice Single Serving Sizes, Infant Juices, Juices with Sugar Added Seneca Frozen White Grape Juice Cocktail

EGGS (Grade A Large ONLY)
DRIED PEAS/BEANS
PEANUT BUTIER
INFANT FORMULA
INFANT CEREAL (Boxes ONLY)
TUNA
CARROTS

Least Expensive Brand ONLY
Any Brand Without Flavoring Added Any Brand Without Jelly Added or Honey Spread
As Listed On The Front of the Voucher Beech Nut, Gerber, Heinz
Water Packed ONLY Fresh, Whole

One (I) Dozen

Any Other Size/Quantity

One (I) Pound Size ONLY

Any Other Size/Quantity

I 8-0unce Jars ONLY

Any Other Size/Quantity

As Listed On Front of the Voucher
Dry Cereal in Eight (8) Ounce Sizes ONLY
6 ounce Cans ONLY One (I) Pound Pre-Sealed Plastic
Bag ONLY

Any Type Not Listed On Front of Voucher
Any Baby Food in Jars or Any Dry Cereal with Fruit or Formula Aided'
Tuna Packed in Oil
Bulk, Frozen, Canned, Shredded, or Baby Carrots

FP-77

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97
Supplement Georgia WIC Program WIC APPROVED ALTERNATE FOOD LIST

Attachment FP-28

FOOD ITEM
MILK (Pasteurized)

ONLY the ~ollowmg .ist of foods rna be purchased usm~ WIC vouchers

..' BRAND OR TYPE -.

CONTAINERIPACKAGE SIZE

UHT, MILK, Whole or 2% (least expensive brand) or Acidophilus, Enjoy, Lactaid 100,
Lactaid, Dairy Ease or Nutrish

8 Ounce Box or Y. GaBon Or Quart of Lactose Reduced Milk

CEREAL

Cheerios, Chex-Com, Rice, or Wheat Crispy Critters, Country Com Flakes, Kix, Product 19, Total-Com, Nabisco Cream ofWheat (Regular Flavor),
Jim Dandy Quick Grits (Iron Fortified), Minute 3 Brand Instant Oatmeal plus oat Bran (Regular Flavor), Harvest Instant Oatmeal (Regular Flavor) Quaker Instant Oatmeal (Regular Flavor) Ke11ogg's Special K, Ke11ogg's Com Flakes, Ke1logg's Complete Bran Flakes, Quaker Sun Country Quick Oats (Regular Flavor), Quaker Crunchy Com Bran, *{Ralston Optima 100 WholeWheat Flakes, Ralston Enriched Bran
. Flakes, Ralston Nutty Nuggets, Ralston Instant Oatmeal (Regular Flavor), Ralston Crispy Rice, Ralston Bran Flakes, Ralston Com Flakes, Ralston Tasteeo, Ralston Crispy Com Puff) *Store Brands AUowed::K roger Kounty Fresh, IGA, Red& White, Flavorite, or Nature's Best

Nine(9) Ounce Size Can Purchase More than One (I) Type/Brand of
Cereal as Long as the Amount Does Not Go over the Quantity on
the front of the Voucher

JUICE

ORANGE: Least Expensive Brand ONLY GRAPEFRUIT: Least Expensive Brand ONLY
GRAPE:Welch's or Juicy Juice WHITE GRAPE:Welch's or Seneca APPLr ;. k"orite, Kroger, Lucky Leaf, Staff, ShurFine, Whitehouse, Thrifty Maid, Seneca (Red
Label ONLY), Juicy Juice OTHERS: Dole :Orange/Pineapple, Orange/Pineapple/Banana, Pineapple/Grapefruit,
Pineapple/Passion/Banana Juicy Juice: Cherry, Punch, Tropical, Berry,
Apple/Grape, Orange Punch, Strawberry

6 ounce can

CANNED PEAS/ BEANS

Any Brand without Flavoring Added

15 ounce can only

PEANUT BUTTER

Any Brand without Je11y Added or Honey Spread

?, ounce jar only

INFANT FORMULA

As listed on the front of the Voucher

As listed on front of Voucher

INFANT CEREAL (Boxes ONLY)

Beech Nut, Gerber, Heinz

Dry Cereal in 8 ounce size only

TUNA

Water Packed ONLY

6 ounce can5 only

CARROTS

Any Brand Without Flavoring Added

15 ounce canned sliced, medium cut

NOT ALLOWED Flavored Milk, Buttermilk, or
Goat's Milk 8 Ounce ofless size boxes
Juice Drinks, Fresh Squeezed juice, Infant Juice, Juice with Sugar
Added Seneca Frozen White
Grape.Juice Cocktail
cny other size/quantity Any other size/quantity Any type not listed on front of
the voucher Any baby food in jars or any
dry cereal with fruit or formulas added
Tuna packed in oil Bulk, frozen shredded
or babv carrots

FP-78

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-29

WIC APPROVED FORMULAS/MEDICAL FOODS

Contract Standard:c,d

MILK BASED

SOY BASED

Enfamil with Iron

Prosobee with Iron

Non-Contract Standard:c,d

Isomil with Iron, Carnation Alsoy, Gerber Soy

Contract Special:c,d

Lactofree

Non-Contract Special/Hospital Based. a,b
Enfamil Premature 20 with iron Enfamil Premature 20 Enfamil Premature 24 with iron Enfamil Premature 24 Enfamil 24 with iron Enfamil 24 low iron Enfamil Human Milk Fortifier with iron Enfamil Human Milk Fortifier

Similac Special Care 20 (low iron) Similac Special Care 24 with iron Similac Special Care 24 (low iron) Similac Natural Care (low iron) Similac 24 with iron Similac 24 Similac 27 (low iron) Similac PM 60/40

Non-Contract Special: a,c, d

Advera Alirnentum Alitra-Q Casec Citrisource Citrotein Criticare HN Crucial Cyclinex 1&2 Deliver (formerly
Isocal HCN)

Enferition 0.5, HN Ensure EnsureHN Ensure Plus Ensure Plus HN Ensure with Fiber Fibersource Fibersource HN F1avonex Forta Drink

DeliverHCN DeliverHN Enfarnil Low Iron

Forta Shake Glucema Isocal

IsocalHN IsomilDF Isomil SF lsosource Isosource HN
Isosource 1.5 Jevity Ketonex-1&2 Kindercal
Lipisorb Lofenalac Lo*Pro

Magnacal Maxarnaid Maxamurn MCT Meritene Methionaid Microlipid Moducal MSUDAID Neocate One
Neocate One+ Nutra Basics Nutren

Nutren Jr. Nutren Jr. w/fiber NutriVent Osmolite Osmolite HN Pediasure Pediasure w/Fiber

FP-79

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97 Non-Contract Special (Continued):

Attachment FP-29 con't

Peptamen Peptamen Junior Periflex Phenex2 Phenex 1 Phenylfree
PKU-AID
Polycose Portagen Precision Isotonic Precision HN Precision LR

Pregestimil20 Pregestimil 24 Pro Balance Product 3200AB Product 3200A Product 3200K Product 80056

Pulmocare .'\.CF Reabilian Reabilian HN Replete Replete w/Fiber Respalon

Pro Mod

Resource

Promote Pro-Phece Propimex 1&2 Prosobee Low Iron Provimin

Resource Plus Restore Restore Plus Similac Neocare Suplena Duocal

Sustacal HC Sustacal Pudding Sustacal w/Fiber Sustagen Tolerex Tramacal Nutri Hep (formerly
Travasorb Hepatic)
Renalcal Diet (formerly
Travasorb Renal)
Travasorb HN, MCT.STD, TwoCalHN Ultracal Vital Vivonex Vivonex Pediatric Vivonex Plus

a. 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 formula may be indicated only for limited conditions. Low iron formulas 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 or for partially breastfed infants/children. See FP- 8, 9, 11, and 14.
d. Ready-to-feed formula may be indicated in limited documented cases such as: 1). Unsanitary or restricted water supply; 2). Inadequate refrigeration; or 3). If the caregiver has a documented condition which inhibits the proper dilution of concentrate or powder formula. See FP- 8, 9, 11, and 14.

FP-80

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY'97

Attachment FP-30

PROCUREMENT OF HOSPITAL BASED FORMULA

Hospital based infant formulas may be ordered by a physician (only) to meet the nutrition needs of preterm 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:
1. District WIC Coordinator or designated staff will fax to OON the Procurement ofHospital Based Formula form complete with the following information (see Attachment FP-30 cont'd):
a. Date b. Name of client c. Birth date d. Diagnosis e. Name of formula f. Manufacturer's name g. Amount of formula requested, list as number of cases or total fluid ounces h. Type of formula, list as ready-to-feed, concentrate, powder I. Estimated time on formula j. Formula issue month k. Prescribing physician I. Hospital discharged form m. Clinic contact person/telephone number n. District contact person/signature
2. Call OON to notify of incoming fax
3. Document request for formula and distribution in participants health record.
4. Verify that the order meets requested specifications, then complete and sign the shipping receipt form . Also complete and sign the DHR Receiving Report and return to the address provided on the form.
Submit order(s) monthly. The total fluid ounces per order must not exceed the maximum monthly allowance. County health departments should receive shipment within 5 working days.
Notify OON immediately if an incorrect order is delivered, or if there is a change in the formula order.
Only a complete case(s) may to returned by the OON to the formula company for credit.

FP-81

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-31

PROCUREMENT OF HOSPITAL BASED FORMULA JANUARY 1994
I. TO BE COMPLETED BY DISTRICT/LOr AL STAFF Date _ _ _ _ _ _ _ __
1. Name ofWIC client _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 2. Birth date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3. D i a g n o s i s - - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Name of formula requested _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 5. Product number/manufacturer of formula _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 6. Amount of formula requested _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 7. Type of formula: ready to feed, concentration, powder, single use bottle, etc. _ _ _ __ 8. Estimated time on formula _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 9. Formula issue month _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 10. Clinic contact person/phone no. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 11. Address/telephone number to ship formula _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
12. Prescribing P h y s i c i a n - - - - - - - - - - - - - - - - - - - - - - - 13. Hospital discharged from _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 14. District contact person _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 15. WIC/Nutrition Coordinator's si?,:cc<.mre _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ CALL OON AND FAX TO FRANCES COOK, OFFICE OF NUTRITION: (404) 657-2884, FAX:(404) 657-2886
IT. TO BE COMPLETED BY OFFICE OF NUTRITION 1. Formula Cost of this order (including price per case) _ _ _ _ _ _ _ _ _ _ _ __ 2. Date order placed to formula company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 3. Clinic/District's account number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 4. Contact person at formula company/phone no.____..:._ _ _ _ _ _ _ _ _ _ _ _ __ 5. Anticipated date of delivery _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 6. OON Nutrition Consultant's signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Ill. TO BE COMPLETED BY STATE WIC BUDGET OFFICER 1. Purchasing authorization number/initial date _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 2. Field Purchase Order# I initial date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 3. WIC Financial Director's signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

FP-82

REVISED 09/96

GA WIC PROCEDURES MANUAL FFY '97

Attachment FP-32

SUPPLEMENTAL FORMULA CONVERSION TABLE Caloric Displacement Method

MonthlyRX

Maximum Cans of Formula Allowed

Infant

Child/Woman

Concentrate Powder

Concentrate

Powder

*Moducal (13 oz. powder)

1 can 2 cans 3 cans 4cans

28

7

32

8

25

6

29

7

23

5

27

6

20

5

24

6

** Polycose (12.0 oz. powder)

1 can 2 cans 3 cans 4 cans

28

7

32

8

25

6

29

7

23

5

27

6

20

5

24

6

*** MCT Oil (32 fl. oz. bottle)

1 bottle 2 bottles

17

4

21

5

3

1

7

2

Infant is allowed a maximum of 403 fl. oz. of concentrated formula per month.

Child/Woman is allowed a maximum of 455 fl. oz. of concentrated formula per month.
* Moducal powder: 1 can contains 46 TBSP/1400 calories ** Polycose powder: 1 can contains 59 TBSP/1330 calories *** MCT Oil: 1 bottle contains 960 cc/64 TBSP/7300 calories

3 teaspoons = 1 TBSP 1 fl. oz. = 30 cc 13 oz can standard concentrated contract formula = 40 callfl. oz. 13 oz. can standard reconstituted contract formula = 20 cal/fl. oz.

FP-83

REVISED 09/96

GA WIC PROCEDURES MANUAL FY '97
TABLE OF CONTENTS Eage
I. Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-1 II. Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-1 III. Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-1 IV. State Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-1
A. Nutrition Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-1 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-5
mM l!i.Y:im:91IfJ:mf.@.!ln:::IS~~P99.i9ii!Mr&:::!!ml~1Il!l:flll@:l:*:l:l@:i*llll@l@l:*:l~lli@~:l:::r:~:*I:l:l:@::*:I~I1l!ll~!'@!!:l@!!!II!~tg
D. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-6
VI. Participant Nutrition Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-7 A. Participant Nutrition Education Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-7
r!i 199Y.Mii!Kti9n!l:nfil!!nt!nl::&B!i:9Ali!lil~Iltl@:l@@l!l@l~::\~:::::@:i~I@if.IMilBi@li.IitllEi.:::::~:;;;:n::IIJ&i.t2
VII. Participant Referral To Other Agencies . . . . . . . . . . . . . . . . . . . . .,.... NE-10 A. Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-10 B. Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-ll
VIII. Nutrition Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-ll A. Criteria for Development and Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-ll
B. Available Nutrition Education Materials . . . . . . . . . . . . . . . . . . . . . . NE-12 C. Procedures for Ordering Nutrition
Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NE-12

GA WIC PROCEDURES MANUAL FY '97
Attachments:
NE-1 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

GA WIC PROCEDURES MANUAL FY '97
I. PIIRPGSE
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 WIC participants.
ll. DEFINITION
"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, educational and environmental factors.
ill. C-rOAIS
Nutrition education for WIC 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 WIC 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 WIC 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 WIC 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 support component of the WIC Program. Nutrition Program Consultants in the
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GA WIC PROCEDURES MANUAL FY '97
Office of Nutrition are assigned to districts/units to function as a resource for facilitating the State's efforts in strengthening and integrating MCH and .WJC 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.
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GA WIC PROCEDURES MANUAL FY '97
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.
8. Develop and implement procedures to assure that encouragement to breastfeed is offered to all prenatal participants, unless medically contraindicated.
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GA WIC PROCEDURES MANUAL FY '97
9. Perform and document evaluation of breastfeeding education, promotion 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.
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GA WIC PROCEDURES MANUAL FY '97
V. I.OCAL 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.
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GA WIC PROCEDURES MANUAL FY '97
2. Provide in-service training and technical assistance for competent professional authorities (CPA's) and paraprofessional staff at local clinics.
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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 Competency Based Skills Workshops are conducted by the Office of Nutrition. These workshops provide WIC 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 flle 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).
E. Nutrition Education Plan
1. Biennial Nutrition Education A two (2) year Nutn.ti.on Educati.on Plan @==Q=:=i=.=m=J==P=g=t=~=i=t==.=t=~=J=i=i=:o'~=f=g~mt:oi:=:=~?f.:l: must be subrru"tted to the Office of Nutrition by IP.W.liillml~ of the appropriate year.
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GA WIC PROCEDURES MANUAL FY '97
a. The local agency Nutrition Education Plan must include:
1) 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:
1) 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-1, NE-4 and NE-5.
VI. PARTICIPANT NJITRITION 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, p!gt.:~::!it.fii!tmn:::::!tlji~:::::gm~J:g~Y.l.!iii~@:!1.!1~! 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.
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. All participants shall receive nutrition education contacts which relate to their particular nutritional risk condition and the need for a well balanced diet.
4. Prenatallbreastfeeding/non breastfeeding women must receive the content by the final nutrition education contact of each certification period.
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GA WIC PROCEDURES MANUAL FY '97
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5. The Nutrition Guidelines for Practice are the established guide for nutrition education contacts.
6. 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 1 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.
7. 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.)
8. 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).
9. A lesson plan must be developed when group classes are used to provide the nutrition education contact. Lesson plans must be kept at the clinic site for use
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GA WIC PROCEDURES MANUAL FY '97
by clinic staff and provided to the Office of Nutrition at the time of program reviews. 10. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing secondary nutrition education contacts. B. Documentation of Nutrition Education 1. All 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 participant's signature on a class attendance sheet or voucher register ll.iU~ 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.
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GA WIC PROCEDURES MANUAL FY '97

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.

Vll. PARTICIPANT REFERRAL TO OTHER AGENCIFS

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

Community Resomces

Food Stamps Medicaid Right from the Start AFDC Heads tart

Aids Program Private Physician Mental Health and Substance Abuse Program

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GA WIC PROCEDURES MANUAL FY '97
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.
Vlll. NUTRITION EIDICATTON MATERIAlS
A. Criteria for Development and Use
1. All nutrition education materials and forms used and developed locally for wrc
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 dffice of Nutrition will seek approval from the local agency to duplicate the materials. 8. See Materials Evaluation Fonn for guidance. (Attachment NE-8)
NE-ll

GA WIC PROCEDURES MANUAL FY '97 B. Available Nutrition Education Materials A catalog of nutrition education materials can be obtained from the Office of 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 by the district WIC Coordinator for all local WIC clinics from the Office of Nutrition.
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GA WIC PROCEDURES MANUAL FY '97

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

BODYOFPLAN Needs Assessment:
Objectives:
EvaJ.uation Design: Action Steps/Activities/Methods: Resources: Milestones of Activities: Attachment NE-1

A statement of the problem. It tells why something should be done. Include facts and/or statistics.
Should begin with "To... " and include an action verb; desired results or outcome; a target group; and a time frame of completion date.
Process of determining the extent to which the outcome is commensurate with State objective.
Tasks that relate directly to the achievement of goals and objectives as identified.
Staff, facilities (space available, etc.), materials and technical assistance.
Target dates for accomplishment of key activities.
Examples of behavioral objectives are for the following areas:
1. Breastfeeding: Increase the incidence of
breastfeeding among wrc participants
from (xx)% to (xx)% and six month duration from (xx)% to (xx)% by (month) (date), 199(x).

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GA WIC PROCEDURES MANUAL FY '97

Attachment NE-1 cont'd

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) (date), 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.

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GA WIC PROCEDURES MANUAL FY '97

Attachment NE-2

NIITRIDON TNSERVICE PROGRAMS ATTENDED BY LOCAL PROFESSIONAL STAFF

DATE

NAME & TITLE
OF PARTICIPANTS

TITLE OF WORKSHOP

FUNDING SOURCE

'
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GA WIC PROCEDURES MANUAL FY '97

Attachment NE-3

NIITRIDON INSERVTCE PROGRAMS CONDUCTED BY T.OCAT. PROFESSIONAl. STAFF

DATE

TITLE AND WORKSHOP

INSTRUCTOR

NUMBER OF LOCAL STAFF ATTENDED BY: DISCIPLINE
NURSES NUTRITIONISTS OTHER

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GA WIC PROCEDURES MANUAL FY '97
DISTRICT NIITRWON EilliCATION

Attachment NE-4

DISTRICT

NUTRITION EDUCATION PLAN

FFY

DISTRICT NUTRITION COORDINATOR:

NEEDS ASSESSMENT:

OBJECTIVE:

EVALUATION DESIGN:

ACTION STEPS/ACTIVITIES/METHODS RESOURCES

MILESTONE OF ACTIVITIES

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GA WIC PROCEDURES MANUAL FY '97

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:

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GA WIC PROCEDURES MANUAL FY '97

Attachment NE-6

GITIDEIJNFS FOR PARAPRQFFSSIDNAI. TRAINING
QnaJifications for Paraprofessionals
Who can be trained
1. WIC 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.
Competencies for Paraprofessionals
Basic WTC Program Knowledge. The WIC 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 WIC Program. 4. Identify the district WIC staff, including the district nutrition consultant, and
where to locate the district WIC office(address and phone number). 5. Locate: (a) the local WIC 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 WIC Program Procedures Manual policies relating to supplemental foods and nutrition education. 6. Describe the process of how a WIC participant obtains WIC foods. 7. List the various WIC approved foods. 8. List notification requirements.

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GA WIC PROCEDURES MANUAL FY '97

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 WIC 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

-Conveying positive body language and attitude

2. Identify problems, during the individual contact or class, which are WIC, health, or staff-participant relationship oriented.

Referral Skills. The WIC 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 Training/Continuing Education

Secondary nutrition education contacts can be provided within the following parameters:

1. 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.

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GA WIC PROCEDURES MANUAL FY '97
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 information 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 WIC 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.
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GA WIC PROCEDURES MANUAL FY '97
PARAPROFESSIONAL TRAINlNG PLAN CHECKLIST FOR ITEMS TO SUBMIT FOR APPROVAL
Training Plan: Lesson Plans for use in training paraprofessionals, including post-tests. May be submitted on an on-going basis. Evaluation 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). Lesson 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.
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GA WIC PROCEDURES MANUAL FY '97

Attachment NE-7

WIC MATERNAL IDGH RISK CRITERIA
Any WIC prenatal, 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. HIV 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. HIV 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.

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GA WIC PROCEDURES :MANUAL FY '97

Attachment NE-8

MATERIAl, EVAJ,JTATJON FORM

Material Name/Title

Type

Obtained from

------------------~0~a-t~e~R~e-c-e-~~v-e-d~---------By - - - - - - - - - - - - -

~----------------------~

~--------

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 deemed necessary
-useful and relevant to target audience
* Appropriate for target audience's 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 are accurate, up-to-date and usable

MINIMALLY ACCEPTABLE

ADEQUATE SUPERIOR

NE-24

GA WIC PROCEDURES MANUAL FY '97

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 are 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 '97

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 '97

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 '97

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

TABLE OF CONTENTS

A. Definitions .................................................. SP-1 B. Season ..................................................... SP-2
-:;.:~
Transfer of Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SP-2] Processing Standards .......................................... SP-:3' Income Eligibility ............................................. SP-~ Outreach and Referral ......................................... SP-:3
:....;:
Communication Network ....................................... SP-:.t .;.;.:
Food Delivery ................................................ SP-~ Reporting ................................................... SP-;f Fair Hearing ................................................. SP-~ JI[ Services For ~P.~!HMR*-~~*-.g@:t;J}ffi~l~~~,iApplicants/Participants ........... SP-~
i'\~
Applicants/Participants Residing In Institutions Which Serve Meals .................................. SP-q Applicants/Participants Residing In Temporary Locations ................................................... SP-.6;-x IV. Services For Other Special Populations ................................ SP-~ A. Non-English Speaking Populations ............................... SP-' B. Refugees .................................................... SP-.2 C. Native Americans ............................................. SP-:2
~; . f.~$.Q~~rtrrill~~Y.1!~;T;:: s:.m~ :.:s:\Ei'ITE'\'J:,:t:,ifl.TT::::isE::,mn:.ngm;;z;:m-:w:sm:m:E;gm
E. Interpreter Services (Hearing-Impaired) ........................... SP-~

Attachments:

SP-1

Migrant Health Program ........................................... SP.-:2

SP-2

Migrant Education Staff/Five Regional Offices ......................... SP.-~-]

SP-3

Telamon Corporation (Migrant and Seasonal Farmworkers

Association, Inc.) ............................................. SP.-fg

SP-4

Interpreter Services Through Georgia

Refugee Health Program ...................................... SP.-~

SP-5

Georgia Interpreter Services for the Hearing Impaired .................... SP.-i~

GA WIC PROCEDURES MANUAL FY '97
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t()t~s:pqp:Ul~t~pp?
A. Definition
antSTocuses.on workers7nMe Pro~ ,. u..n...a.. ti ca.,.lJ:lY:?.,W' . .I.C:.....".s. de:0l.i..i.J..i.t'''io..l.. f. of'f. fi'i~.W.:c.ec... ..''. "farm..... ."- ..:''';<=><.:,,
recO'@ize~ .9~~fL~~f!9W~W P2PP~~q~ ?~9gn~. a~ffii~{~its. A~99!!1!i
empl6yni:erit.t~f~r$ !<? pc~p~ti6i:iS f.~l-*t~g;~q_ tp~ . pro~\}cti9n,. J,rr())Yipru;}lm!g
~~SY.~st~R~:.8f:~x.:sP.tttm.~C#o/.~2&~mi.2t.:effi5th~rlan~l:2(.t'~.()r:~rs~~9i!M St"9~~.m9K<:>;\tfiti.~'P +li~h~~~g:t:tt~~-'ffi~~-tP-~4@ti9n2fi:i~fismtm!
os9-P~tiql.1/.:m~::wr<:;:ptq~;~s9~#.$ !9.~~f#wh9 Hi~ft99tll~~dJ!!~~2f
~~()pa.l eiliR~oY:W~P:t~~tIrir&;~~~~~RF~t9tfl~~ pt@p~~-<?fsticJ:l, ~~p~q~~F,~ ~~ ;Wgr1s~ !ljt~;~~j,~~~2~!K~~tmw:~rtB:t!S~f~.r~~:f!ltrm1#9~M,~~u~g~~wrgt1m~p;f~
m~x:::.pq.;:9EiA12~lli89.t:Ia::::i~~t;~~!?8~!t:1.!~9t~#t~~!g~p~~--fr:~ffiP.!2@1~]~] l'l#.P?~~;mp;;p;s!M~m~,~:;~:~!!~h!~t;(!4.~:~&ll'f~~:::m~;m~YJ:g~!!nti.!lj
~~-~fm9.~f\IP. .~.g;;i~R:!ff:~H.m!$t~Ytt::;~tt~~ ~. ~!PPJ~~~g:,1!1 @:J~msP:!m
2t:SH#~9.*.@;J~~Y/%t:twP:9t~:~~!N~&~~t:~r;pu~:efript9.Y.!#.*P
SP- 1

GA WIC PROCEDURES MANUAL FY '97
M!~![~~Jii~~lijf.cliYf:9.-9!T.~Ii[~g~]f~!tf~*iim~9!9~~lilifWR:!2!JJi!!
~~~~-ili.i{ll1flliili~iilll~!.l~l
............. . <:i~P.!t\9.!11i~!1Wf:Y!~!!!~!Yrf.f1~~~-~fi'~T.
~ll~litl1\11-lli\III&B\1i
~~~3~<?!::~:'m~11!~'~~*=~1J.ilii:~1Jilemr~BKmm:9xcmtmllmll:u~~;~.
t,~mr:~~,~g1ie:.~~3 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." Alba..1y 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
SP -2

GA WIC PROCEDURES MANUAL FY '97
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 of whether the VOC card is entirely filled out, the receiving local agency 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. ';~?~~~~!f2n;fqfmi:IIQ!mR~N9Ji:~~l.pr~p1if.#9:":~!i~~g~~~s:1!:~~q~9 t9i~,PP~~~
E. Processing Standards
Migrant farmworker families will be notified of their eligibility or ineligibility within ten calendar days of their 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 nrlgrant 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
SP- 3

GA WIC PROCEDURES MANUAL FY '97
shall make every effort to provide access to health services for migrants and their families.
H. Communication Network

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. Migrant activity and expenditures are

also reported on the Quarterly Status Report. ~~X;fi~,;E~~EH~!Wlt:~

~g~totmt:~:;.~~;l.i~~.~:;;~~rt.~.:.:rro;'{c'~e~~~.;dP.;:t.rl"Pe:.t:liiillli~t;w,;~;~~'Fs,:,Xfti~~~Al!

mom oreu::::accorutng:, :<Y>pr.

onngr ec uures:<:as::Ou~;.l:llJ: u"~tu.u-.4.tYJ.Om

onrh:>:~

~E~~~

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

SP -4

GA WIC PROCEDURES MANUAL FY '97 should attempt to fmd 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.
ill. SERVICES FOR ~~~~iJ!J.J!IQ~:\:PI~J!:~=~n~~O~J.:E~~S'APPLICANTS/ PARTICIPANTS De.fiffitions
:.:..: .. -...."..:;->;:
B A.-.-P..P'I.i..c..'-a'.n..t.s f.P,..__a.,,r_.u,,,,,C._.,,i.,.Pa..,n.._t.s..,.R...e....s..i...du.i...Jti.n..'.I.f.i.s. t.iru--no..h s. W..h..i.c.fiTS.etV'e :.M..,..,e.,. a,..l..s..
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 for battered women, etc. An outline of the 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 of related persons, i.e. a mother and her children in a temporary shelter for battered women, does not include other residents ofthe institution. Income of the institutionalized person is also separate from the general revenues of the institution.
SP- 5

GA WIC PROCEDURES MANUAL FY '97
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 of food provided to WIC participants.
3. Food items purchased with WIC vouchers must not be used in communal feeding. lfWIC 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.
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.B. 2, 3, and 4 in the above information were discussed and are understood by the applicant/participant.
3. Each applicant/participant has been informed oftheir Rights and Obligations, both verbally and in writing.
C. Applicants/Participants 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 of WIC 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 building, temporary shelter, hotel, motel, etc.; and
SP -6

GA WIC PROCEDURES MANUAL FY '97
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 of the 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 must 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:
1. Discuss spreading out redemption of vouchers over the 4-week period.
2. Offer information on food storage and sanitation, when applicable.
SP -7

GA WIC PROCEDURES MANUAL FY '97 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
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 carry out outreach activities to insure that eligible members of such populations participate in the program. Contact should be made with other agencies and community organizations 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 ofNutrition (see Administration Section, Attachment AD-5).
If a local agency needs materials in other languages, contact the State WIC Office and the Office of Nutrition for assistance. ~S~.:t!~r$&J!~~~5~~JI~
:~llf.Ziiil~~~~liill~ll'fll,~l!:&\lttl~*;\m!i~}2
SP- 8

GA WIC PROCEDURES MANUAL FY '97 !~9~IJ!g~~fgT~@~!fS:9~s~;;tg~g1Vf.~U?!!m~t@l%~~t:JA~il'~,P!..s~~:.;if. l?t()Y}~e~:m~~~:;~~n:~,s~~;::.::~!i@f:t~':t@~~~:wr~r~!~li91:r~~tie,.s:;~~:;:$Y.!Y!l>l
Qlt9Y@ .th~1.~!~t.~~~~ffig~l::f!~~~~:pf~~~i:.~::\tpes~c ~e~ t!f.91~::$~!$~iJ!!Y:~
~ri~~~~~~~~~~K~;~ii~~~~1;~~i~~f~:~i~i6:bf~,~~i~rNPR
B. Refugees
~~~~~~i~~~~iii~~~~,t~\~5~!~\\,~~fl~~~~~~~i~l~~~~~~Ji
f:tt.!~P#!~f.Hp~:~.iie2i.Wi~P~?With the significant ntunber of refugees, such as
Cuban, Haitian, ~~l@.~:and 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.
C. Native Americans The WIC Program should make every effort to locate and enroll all eligible Native Americans.
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 '97
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-1

Health Director

Migrant Program Staff

Columbus
I
Macon

Mary Anne Shepherd, FNP & Project Coordinator P.O. Box 346 Ellaville, GA 31806 (912)937-2308
\
Helen Hudson, Project Coordinator P.O. Box 1149 Ft. Valley, GA 31030 (912) 825-6975

Valdosta

Russell Paulk, Program Manager P.O. Box 5147 Valdosta, GA 31601 (912) 333-5290

Waycross Albany

Frank Stilp, FNP & Project Coordinator P.O. Box255 Metter, GA 30439 (912) 685-5765
Gayle Womble, Adult Health Director 1109 N. Jackson Street Albany, GA 31708 (912) 430-4576

County Served
Schley Sumter Mac.Jn Taylor Crisp
Crawford Peach

Contact Person
Vicki Wilder Luneda Brown Brenda Oglesby Dorothy Brown Alicia Brown
LindaHouch Bertha Ashley

Phone Number
(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 Tattnall 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) 896-303 (912) 559-510~ (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) 981-7100

SP -10

GA WIC PROCEDURES MANUAL FY '97
MIGRANT EDUCATION STAFF
Ms. Michelle Rosinek, Consultant Georgia Migrant Education Program
State Department of Education 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, GA 31709 912/928-1290

Migrant Education Association Live Oak
P.O. Box 826 Statesboro, GA 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 770/536-5717

Southern Pine Migrant Education Association P.O. Drawer 745
Nashville, Georgia 31639 912/686-2053

SP- 11

GA WIC PROCEDURES MANUAL FY '97

Attachment SP-3

.. TELAMON CORPORATION (Migrant and Seasonal Farmworker Association, Inc.)

Herbert Williams, State Director 2720 Sheraton Dr., Suite 140D Macon, GA 31204-1167 (912) 873-6575

Field Offices

Offices Valdosta Office 1012 Williams Street Valdosta, Ga 31601 (912) 244-4920 (912) 244-4921 (FAX)

Supervisors Carmen Wilkinson Program Coordinator

Lyons Office 143 East Liberty Avenue Lyons, Ga. 30436 (912) 526-3094 (912) 526-6850 (FAX)

Elmira Reynolds Employment and Training Specialist

Dublin Office 112 East Johnson Street Dublin, Ga. 31021 (912) 275-0127 (912) 275-7548 (FAX)

[~~~~~':~2B Employment and Training Specialist

Douglas Office 613 West Baker Hwy. P.O. Box 966 Douglas, Ga. 31533 (912) 384-8856 (912) 384-8929 (FAX)

~i~E~!.~ Employment and Training Specialist

Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, Ga. 30358 (912) 764-6169 (912) 489-5616 (FAX)

Elsie Trethaway Employment and Training Specialist

SP -12

GA WIC PROCEDURES MANUAL FY '97

Attachment SP-3 cont'd

Offices
Moultrie Office 19 1st Street S.E. Moultrie, Ga. 31776 (912) 985-7507 (912) 985-7305 (FAX)
Blackshear Office 3351 West Highway 84 P.O. Box413 Blackshear, Ga. 31516 (912) 449-3016 (912) 449-4579 (FAX)

Supervisors Beverly Scretchen Employment and Training Specialist
:::::...::.;.;.;.;.;.;.,.;.;.; ...y:;:::::::~:::.:
Deputy Director
fiffi~~~9~9.!1 Employment and Training Specialist

1)

Ms. Raynita Smith

2)

Ms. Susan Johnson

KlDDLE KASTLE I

KlDDLE KASTLE II

684 N. Washington Street

Ill Oliver Lane

Lyons, Ga. 30445

Glennville, Ga. 30427

(912) 526-9558

(912) 654-2182

(912) 654-2190 (FAX)

KlJDDEE';KA.:STL'EJll
ii.~)i~~~j~!!~~'''"''
~9!m!l~l.S";~)$711
~~!Jt&s~.ii26Z

SP- 13

GA WIC PROCEDURES MANUAL FY '97

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

Afiit:Jassil Director .;.;.;.;.;.;.;.;.;.;.;:;:;:;::.:-./L: ~ .'
Lori Laliberte..:carey, Health Services Specialist

(404) 657-2552 (404) 657-2563

COUNTY COORDINATORS

Dao Hongkham (Lao, Vietnamese) Senior Community Epidemiologist Dekalb & Clayton Counties Dekalb County Health Department 440 Winn Way Room 137 Decatur, GA 30033 508-7785

Dung Krall (Vietnamese) Senior Community 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

(770) 531-5600 GIST 261-5600

SP -14

TABLE OF CONTENTS
Page I. General .............................................................OR-I II. Methods of Outreach ...................................................OR-2 III. Agencies to Contact for Outreach .........................................OR-2 IV. Public Notification ....................................................OR-3
VI. Outreach During a Waiting List ..........................................OR-4 VII. Program Costs ........................................................OR-4 VIII. Logo ................................................................OR-4
Attachments:
OR-I WIC Outreach Card (Small) .............................................OR-8 OR-2 WIC Outreach Card (Large) ......................... : ...................OR-9 OR-3 Flyer/Poster .........................................................OR-10 OR-4 Georgia WIC Resource Referral Guide ...................................OR-11 OR-5 Georgia WIC Program Fact Sheet ........................................OR-12 OR-6 WIC Logo ...........................................................OR-14
9R71 PuofiC'~Vfee1iilgJ?:7/r...-~,:.'' -,..,. <' < , >> .....;.,....,. ,.,..

GA WIC PROCEDURES MANUAL FY'97
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 ofpregnant 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 of the WIC Program's qualifications 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-1

GA WIC PROCEDURES MANUAL FY'97
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 of informational posters, brochures, displays in public places, presentation at meetings and clubs, and advertisements through local newspapers, radio, or television. If a local agency serves a significant number of persons whose primary language is not English, the local agency must make outreach materials available to this population in their language.
The State agency has developed the following outreach materials for local agency use:
1. Outreach Cards (See Attachments OR-1 and OR-2) 2. Flyer (that can also be used as a poster) (See Attachments OR-3) 3. Georgia WIC Resource Referral Guide (See Attachment OR-4) ~: ~:@:;f~l!t.g~;:;~~~Bm~I.i~~t~~
5 ~R~!~stiet!.9~:;~2}!g~pi~J1!iffltp~~~if~f:I@l~n~2!I!!~ 6. Logo- (Developed in FFY'94) (See Attachment OR-6)
III. AGENCIES TO CONTACT FOR OUTREACH
Examples of agencies, offices, and organizations which should be contacted regarding outreach, referral, and coordination of services include:
1. Alcohol/drug abuse counseling and treatment centers 2. Family Planning programs 3. Child abuse counseling centers 4. Physicians, Nurses/Nurse Practitioners 5. Health and medical organizations 6. Hospitals and clinics 7. Pharmacies 8. Welfare offices 9. Unemployment offices 10. Social Service agencies 11. 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
OR-2

GA WIC PROCEDURES MANUAL FY'97
17. Retail Stores (Kmart, Walmart, etc.) 18. Day Care Centers 19. Charitable organizations (Goodwill, Salvation Army, etc.) 20. Headstart Programs IV. PUBLIC NOTIFICATION The State agency, through the Office of Public 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.
TJX~ ae.g;~i~ iW:f:ftg~ ~9!i<?i~~publi~;()fi,~~t~~~g~S,J~i~'$ttef>llili.of op~Tii~i.B
::i!t:~::;!s~=;s"5~i&
fuid. grotJ.ps, .Jhef()lloWilig -lj~ingsare exartjpl~s_(}flo~at grolips ~<)}iped With tegatd~o.m~
public he@hg~: ~oatdS ()fl{~tgth; Ec~norilic OppgrluilityAutho4W~s, CommunityA:~t~p!i ~genqi'#~~lMi~~ ~4'~~()p.alFfutilvvofke~:j,\~oi~ti,()n; tJ.fat~~ tifDiriles, Divi.~i()h.<)f
Fa.m-... ilY.....a..n..d. Ch.i.l.c.4-'-n..-Setv.i ce.s...fL_,e._g.:al..A..id:.So..Ci.e. ties.~.-f{e.ad---S.-..f..i.i-rt P-.,..:..to..gtain.s.;unemP1.6.Y_l.P. ..e...r.i-t
O~airil- ()eiite~s} li()spitals~ .Jcted pflicials~ ri$8Q~:it~<jft$; 9felectd offiCials, ch()ft}se~; ~pgio~:gr()tip~p$p&i~t;lgt~~~l1e~tgtgro!f.Ps~~2n1Y:~~~tP~~::t~sroots otg~t!<)~~~
copunUflity -h~#fP.;.p~~t~sn:~~1 ':"erid()rs a,litt srosr~ asssiatit)ii~
A-' Jist .~t.!~~~tii:J.~i:fu(:l'~()ti~t. -pef9~'liefti _ pl1bli~Atg:tgs:~y~re h~ld in -J;y;l??..i.~
i!.~h4~I:~laii~t~~~~!g.9c?.Hi4~t~~t12PJ~~~P?P.!~$_{)t''~:~~Q?!~314._.Pr94Yit~~ M~ual$tnPtiP!![ailiti~$:tp:ert11~~~.19al.4~altli;:4~p~e~~~tc>t~Y.~~)Y:pri,()t.tg.!a~ PU..b..li.c...h_. _@._._ ..ri_gs.__(___s__.~_..e._.A..tt.a.c.l)-.i..l..i....nt OR..../7. )__.
and W..IC Pr:q.g"rar.i.l.. .r~-gula.l.i.o.n.s.: ......g.u..idelli.ie,s,,ar.e..r.n..t\.C..l...a.v.a.i.l.a.b.l.e:;t(i..;.f..].:.i..~-.1'l..l.[.jl.i.c. up,..o..n...~.e..g.U....~..s.t.;.
This inclfides.tlie Federal Regulations,. the State Pian;.me;.Procedures'Manual arid:the Irtcome Gilidelines:Whelithe WICProg:tam Cd,ordinatots give~terviey.rs to:locaLtn.edi~ <>ti~etS,tJ.i~ ~!~~11t ~! P~9.!P~t!p~in..)Y:J:Q il~ siiJ:ti~itRfV~tX()nef.ig~<!Iess.<)ftgqe; color, n~~onruorigill;age;~X:,or.h@:t1ic~pJsinslt14e~?:Irlfof$ati()p<>n 'o/;4et--~dli2WJli~
OR-3

GA WIC PROCEDURES MANUAL FY'97
VI. OUTREACH DURING A WAITING LIST When local agencies reach their maximum caseload and a waiting list is instituted, outreach activities should be concentrated on the highest risk population.
VII. 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.
VIII. LOGO In FFY'94, a new logo was developed by the State WIC Office. The logo represents a mother and her children (see Attachment OR-6). OU!FRE'ACH/COORDINATION
. ......... ... h~>'..''':::~, _.~,__,,,,, -.
A. Outreach
li r!~~9!?!~~8!!?.-gs 2; Stickers
3:: smi6afis
,-;;:,. :..;..'.>:>>>>: .:.<>.
OR-4

GA WIC PROCEDURES MANUAL FY'97

TheY:: Cij:$tributethese :matef!~s' ~o referta:}~ag~~c~~.]}Y:i@n .thit prqgr~ are{ Tl;ie
Stateagcency supplie~ som~ ()f1bese materialsa.ng th~)()cal agensies aqct!hefr na.nie~;
~d~se~; and telephone *umbt~; . Many refertaLsezy.i,ces a.te;.lit)useddfi cofulcyhealth dep~~pts 5uch a5 ra#Iypiat)ryi,ng, :Pien~~; i#i#.tllm~~#?1.~4shli~~~alth slihis~~ .P oS....t..e...i...'.s....,.a....n...d PriD......ted.m.....a. terialsabou t th..e W...I.C..P.:.r.c.r.~ .. '1...a..t..ea l..s..o...:..d...i..s..Pl.a..::Y:..e....a.......i..li f.e..e.. eptio.n
areas~

Jlie n~WGeorgia wrcJogcff~~ Attacliirient OR76)W~:speeialtydsigi1~4'to effiiance
.... . .. .. 6fitr~~~~~~ffoit~ to PriY*~Pi<?!4~rs) ~~f1~~~srq@~tt~.tJ?.(>f~~n#~ttgris~

l1ieW. -ICH. OTLINEc. ori.tiiiu. estO'be

availableforomreach. . .. ,. .

.... ,. '

.The ,.. ..

...

WIUHOTLINEwas "

.

... .,, .. ;.

inSt~l~d to give vendol'S, clie4ts; staff:'~q the g~~i~f~.p~glicqifect~S~~~tot}l~ ~t~}

WIQQfflc;e atno c()~t. J1rist~,!lo:;reeri.\tbf,J~8QQ;..7~~-:2J7?.tis c1Ya.i~.:tl:)le onpriritd

m... at'e'r'ia :l::s.:.::a.:.nd is p ro...v....i..d....e...d......d....u......r'..itr~ radio:and tele\dio:nintetviews; ............ <...>.'.::::.;......................'.':.'..... ;....



The/f\:venty-one (21) local agencies ate ertt,ouragd.JO.~om;finin.i~ate\tgt.tla:t~YWitli
agp.9i~~;prov,,iding. ~.~I"V~c~~!O:'m9th~~i~c!i@sW@~t1fl:ie~~ gg~~9ie$. ~ei!ldiu~~v)qf
goy#~~ptal,.qtiasi~g()~~hffi!, aii4priy~1o/:JJ91f.!9!7P~~!i~;tgt:il#.~t!9#~;and~!~~#
partiip~tion groups, .E~ariipl~$'()fagel1~ies, office$'.and qtg@i~tio~)vffi.hshotild b~ contc1dteciregarding.the. ott!~~sQ.;referl'a!.~t:Ic<)()fg~i~!!P49t''\Y!P~~rYicesi~(';!ti~~;
a}cof1Q1(4[ug .aouse ;9~~~mg:;snteti famiJ.Y:.ti?l~S.P #i~ttn~~<l 1ri14 p;etiJf progr@:.l$.; EPSI)T,clli!<i <i~~~S9~lytg~A!~i'S~;p~lif!M ~~1ciic#&tgitilJ?c1tigh~~ }1ospit~~,cmd.cJinic~,"elf.~~}pfYcesf!ifl~giP.~l1~@!P9~c~~~;~()ci#l.~etyJe. ~~P.si~
. :~~~;~~d~~:;~~.~~~i!t!~~~:~~~~1:r~~r~:~~~d ~~~4::1r-

1 ~ m~::<fistribution ()f:'t}~~ Geo~wa W!(;i:Re[eiTiiT1?1#.~$~9ltey!~ i:~~)'ilf~e b(}01d~t ~ ilifoim clients ofother l'rogt~s~

WI healthcliiiiecse!Yices beenamajor Inte~,....l.i.o. n of :

c services.:.\.\..j..t..h..~.o,the:f .. ....

haS tbiUSt fdr. .:.. ......... ,................., . . . . . . . . . . .: .. .

the State:.:WICOffice.and the DivisioilnfPublic'iHeattli;? All :disfrictshavtflakeri

,. .. -:- . ..'>.'.-.: :.:-:-:" . .,::' ' . .

: ......... _.,._,_. .:...... .

. . ;

..-.---:::-:-.< .-:-:-. _.. .:-.:-:.. ;:._._._ ... ... ..... -...... -

. .... ; . . ~--. . ....... - .. -.

OR-5

GA WIC PROCEDURES MANUAL FY'97
~:1:~''
OR-6

GA WIC PROCEDURES MANUAL FY'97

ist() !nJ.prove ~eryice d}tyery ~d acce~~Jo seryices for potential p[:utiCip@ts

by integrating/c<?<>tciiliating 'the '}~pplicatioll/eligibility. process; thereby

elihifuatifig oigr~~tly:f~~~9f&~ilieclupli~atiort bfservices.

. ...

d. Astan.on-goj.rlg effort; ilie<Oeorgia?WICPrograni'hasonstaff'a meaiehl
~:Pi4enii~jlogist :}~h6;i ~ ~tifr~n'tlyi~Qll~btll;lg ~d analyiirig data or_{; -~#til
qgttopi~~for )yl:'}i~Cip@t~~,.-This 'WiJI: ~gable th~--.~tate._ agel1.Y. to fully
~ses$i:lt~ illlp~~!9f"W:l9(MeciiGaidcoqtctiha~op on iruhlJ.friiortali:tY F~~r; ~ ~s()q~tiorf\p~!;s~li gal"lY' preriatitl Jg efl!bllriieritand._prenatal c~.Js
(>ei1lglfiy~Stig~1~4~

.W... .I..C.-..i..s..1...i..e..s..r~......e...a..t..o P:..r..o..V..,.,i..d..e.:,.i:.,f.ot:cth.e......r..i..u....t..r...i..t..i...o.....rialca.r..e......<...>...fJ? arti...t..iP.a.n...ts. some Ho. we....v. er>.....:.........
~;==~tlEJSi~:ei~~~~

WIG soutesqf.tfettals-fqt.loca1

Ptpgrifuis~ asw(!llas~ loca} ~d st:ateinter-ag~t~y

Progr~s.. Refefnils az-e ~se11t~alfor tl1~ coordination and the maximizati94 ()fsery!ss~
and tesoifrc~s~

It is.~ o!l':g()iri.g.~ffort;fof 1ocag)YICPro~lO'i:tlah1'Wn refelj~ iilfonriat!onf9i:~t!f

locat~on/ A)'ef~rta.I ~[i)'.p~Jth:Ir!al()fit1fo@al> @sdepends]lporrthe re.asoil for~
referral~

Otb:ei"ifood 'i\gsistafice"pfogral)1$>~d:5ervi9~s tliat are cotfuno!J:refeJ::ral r*()ifrce.~~~fgr

!9Y.~ ~C ~()~s fu9.l.~i.i~~ gggd,S#tmp Pt9~s; :f~()4 Ba.b}(; J"q~>d Coop~iy~~~

C. .h.ut'c'..h..e. s.' /S... yh.

a_go.Ji!.u...e..s'~"F..o..o d...

P.. an..t.;r.i..e.s;,

S...a.l..V.... atio. r..t..A. m. iy;

. :.Geriei'iil.Assistance .>.:. ... ' . . ...

EtindsJill:d
.... ......................

othetcqiri111Jiliity (?rgariizat!()&~ Sli~h asfhitetN!fes; sororities, .ari<l.dt1bs; etc.

Updating tfeiral reS9llfC~$ Js\'an.. 611.--g()ing_pt'Qcessto maiJifaiii .cll:treilt-fe'@
iriforn1ation:T. Localagenties reVieW artd revise resotl.rceiriformation periodic~lly~ 1].~ state WIC Program will reviev,: l()calagencit;:s' referral mechariis~ dUring momtot.i#~
visits.

OR-7

GA WIC PROCEDURES MANUAL FY'97

WIC OUTREACH CARD (small)

' It you ~ e.xpecthg- a

baby~..or atrmy hM

small cMdrel'l.. WIC can he[j:).

you eat better.



The Womtn.t Infants and

Chlldttn program gives.iQ!

~o lowineOI'r'IQ' pt'l?~t
women1 rn:w mot!w's
and st'r'lan ehildrqn, Ask

yourcol..ll'lty he..-th
departmenU,cw ~o
quaRry 1cr WJC, .caJI
1.SC0-~8-917l.

Attachment OR-I

FORM#3752

Ifyou are going to M'l'f! a baby,gei ..

m..'iritior~ intormation al"'d ~ medical .

. ...

~~. rr.~ rounty :he<ith d~pment ~~'Fan !':'



help.
After


tbt

. baby

is

. .
oom,

. .. .
stay hMihY

~;d

$,Nt</~/,>:<..

:

baby htiithy toocl.Emsttmingis b~H~J::m9s,t: V

babies.

,::.,. / ..

WceICreacla,npheat'nlpuytobuutgteert,rbneilka1nschaenedsbearebsyswsrtfmllutle~',r;

E.=-~.::=:~;1::1

:,:,, W~l>t.~.

. .. . .. : ..:'!'. _. r:.

OR-8

GA WIC PROCEDURES MANUAL FY'97

Attachment OR-2

(Front)

WIC OUTREACH CARD (large)

(Back)

Form #3765 (English) Form #3754 (Spanish)
OR-9

GA WIC PROCEDURES MANUAL FY'97 FLYERIPOSTER

Attachment OR-3

Form #3749 (English) Form #3733 (Spanish)

OR-10

GA WIC PROCEDURES MANUAL FY'97
GEORGIA WIC RESOURCE REFERRAL GUIDE

Attachment OR-4

Form#3297 OR-11

GA WIC PROCEDURES MANUAL FY'97

Attachment OR-5

Women, Infants and Children Nutrition Program (WIC)

FFY 1996 Fact Sheet

Georgia Department of Human Resources

WIC in Georgia

The Women, Infants and Children Nutrition program provides special supplemental foods, nutritional counseling, and breastfeeding support and education to low income women and their children up to age 5. WIC is 100 percent federally funded.

WIC gives pregnant women, new mothers and children vouchers for basic foods including milk, cheese, eggs, cereal, dried beans, peanut butter, fruit juices and (for those who do not breastfeed) infant formula.

WIC staff encourage women to breastfeed and counsel them about nutrition. They identify affordable prenatal care and encourage them to apply for Medicaid, food stamps, AFDC, immunization and other services.

Georgia WIC will spend $108 million in federal funds during FY 96. An additional $36.8 million in infant formula rebates is anticipated.



Georgia's WIC program is the 8th largest in the nation and 2nd largest in the

southeast.



WIC reaches over two thirds (71.75%)ofthose 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 221,019 women, infants and children during

November 1995, up from approximately 118,000 in the fall of 1989.



Infant formula rebates gave Georgia a $25.5 million savings last year. This allowed

the program to serve thousands of additional clients.



WIC brought about $135 million into the Georgia economy last year (Oct. 94 -Sept.

95).



The average WIC benefit is about $41 worth of food vouchers per month.

OR-12

GA WIC PROCEDURES MANUAL FY'97

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 immunizations, for their children.



Every dollar spent on WIC saves up to three dollars in health care costs, according

to a national study.

To qualify for WIC benefits, a woman must have a total family income of no more than 185 percent of the 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 priorities are: enrolling women in their first trimester of pregnancy

and encouraging women to breastfeed. J?:o/Qllipg,;~~!~l!~:\lgl~~t!?t~11~~1~Ii1
hi~pg<:J)j!Y;



A women or child on WIC must be at risk of 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 benefits for themselves or their children should

contact their local health departments. In Atlanta, WIC applications are also

available at Grady Hospital and Southside Healthcare, Inc.



An income of 185 percent of the federal poverty level equals:

Family Size

Yearly Income

1 2 3 4

DHR Office of Communications February 1996

OR-13

GA WIC PROCEDURES MANUAL FY'97 WICLOGO

Attachment OR-6

OR-14

GA WIC PROCEDURES MANUAL FY'97

Attachment OR-7

PUBLIC MEETINGS/DATES

Georgia Department Human Resource's WIC Program held public meetings during April1996. The public meetings gave local citizens a chance to comment on how WIC services were provided in their community.

State WIC Office Aprill6, 1996 SW Regional Library 3665 Cascade Road, SW Atlanta, GA 30331 1:00 p.m.-3:00p.m. Laverne Small
Rome 1-1 Aprill8, 1996 Floyd Co. Hlth. Dept. 315 West lOth Street Rome GA 30161 3:00p.m. -7:00p.m. Rosemarie Newman
Dalton 1-2 Aprill8, 1996 Walnut Sq. Mall Mtg. Rm 2150 E. Walnut Avenue Dalton, GA 30721 11:00 a.m.-2:00p.m. Sandy Akins
Gainesville 2-0 Aprill5, 1996 Rabun Health Dept. 465 W. Savannah Street Clayton, GA 30525 10:00 a.m.- 12:00 p.m. Jean Garner
Aprill9, 1996 Franklin Co. Hlth. Dept. 6955 GA Hwy. 145 South Carnesville, Ga 30521 10:00 a.m. -12:00 p.m. Jean Garner
Cobb3-l Apri115, 1996 Douglasville Health Ctr. 6770 Selman Drive Douglasville, GA 30134 4:00 p.m. - 6:00 p.m. Valerie Harrison

Aprill8, 1996 Marietta Health Dept. 1650 County Farm Road Marietta, GA 30060 4:00 p.m. - 6:00 p.m. Valerie Harrison
Fulton 3-2 Aprill5, 1996 Center Hill Health Center Conference Room 3201 Atlanta Ind. Pkwy. Suite302 Atlanta, GA 30318 3:00 p.m. - 5:00 p.m. Marestine Crowder
Aprill7, 1996 South Fulton Annex 5600 Stonewall Tell Road College Park, GA 30349 3:00 p.m. - 6:30 p.m. Phyllis Carter
Aprill9, 1996 North Fulton Annex 7741 Roswell Road Atlanta, GA 30350 3:00 p.m. - 6:30 p.m. RickRayer
Clayton 3-3 Aprill8, 1996 Battle Creek Pub. Libr. 865 Battle Creek Road Jonesboro, GA 30236 4:00 p.m. - 8:00 p.m. Kathy Thomas
Gwinnett 3-4 Aprill6, 1996 Washington Str. Comm. Ctr. 4138 School Street Covington, GA 30209 9:00a.m. -11:00 a.m. Maxine Moore/Lisa Dean

Aprill8, 1996 Rockdale Co. Ext. Service 1329 Portman Drive, Suite #B Conyers, GA 30207 9:00a.m. -11:00 a.m. Maxine Moore/Lisa Dean
April19, 1996 Gwinnett County Justice & Administrative Bldg. 75 Langley Drive Conference Center A Lawrenceville, GA 30245 9:00a.m.- 11:00 a.m. Maxine Moore/Lisa Dean
Aprill9, 1996 Norcross Housing Authority 19 Garner Street Norcross, GA 30071 1:00 p.m.-3:00p.m. Maxine Moore/Lisa Dean
Dekalb3-5 Aprill7, 1996 Eleanor Richardson Hlth. Ctr. Bohan Auditorium, 2nd Floor 445Winn Way Decatur, GA 30030 4:00 p.m. - 6:00 p.m. Carolyn Wetzel
LaGran~e 4-0 Aprill7, 1996 Alexander Memorial Library 99 Sims Road McDonough, GA 30253 10:00 a.m.- 11:30 a.m. Blanche Deloach
Aprill7, 1996 Spalding County Library 800 Memorial Drive Griffin, GA 30223 1:30 p.m.-3:00p.m. Blanche Deloach

OR-15

GA WIC PROCEDURES MANUAL FY'97

Attachment OR-7 cont'd

April18, 1996 Ethel,W. Kight Library 601 Union Street LaGrange, GA 30117 9:30a.m. -11:00 a.m.
April18, 1996 Carroll County EMC 155 Temple Road Carrollton, GA 30117 1:00 p.m.-2:30p.m. Blanche Deloach
Dublin 5-1 April18, 1996 Salvation Army 1617 Telfair Avenue Dublin, GA 31040 5:30 p.m. - 7:30 p.m. Wanda Foskey
Macon 5-2 April18, 1996 Oglethorpe Homes 1130 Oglethorpe Street Macon, GA 31201 9:00a.m. -1:00 p.m. Shirleen Crocker
April18, 1996 Perry Housing Project 22 Perimeter Road Perry, GA 31069 1:00 p.m.-4:00p.m. Shirleen Crocker
April18, 1996 Forsyth City Hall Annex 26 N. Jackson Street Forsyth, GA 31029 9:00a.m.- 1:00 p.m. Shirleen Crocker
Au~usta 6-0 April11, 1996 Oakpointe Community Center 730 East Boundary Augusta, GA 30901 1:00 p.m.-3:00p.m. Frances Wilkinson

April12, 1996 Darling Hall (Soldier Service Ctr.) Chamberlain & Rice Road Fort Gordon, GA 30905 10:00 a.m.- 12:00 p.m. Frances Wilkinson
April15, 1996 Burke County Health Dept. 322 Dogwood Drive Waynesboro, GA 30830 9:00a.m.- 11:00 a.m. Frances Wilkinson
April16, 1996 Harlem Clinic 5915 Euchee Creek Drive Grovetown, GA 30813 9:00a.m.- 11:00 a.m. Frances Wilkinson
April16, 1996 Screven County Health Dept. 416 Pine Street Sylvania , GA 30467 1:00 p.m.-3:00p.m. Frances Wilkinson
April17, 1996 Wilkes County Health Dept. 204 Gordon Street Washington, GA 30673 1:30 p.m. - 3:30 p.m. Frances Wilkinson
Columbus 7-0 April15, 1996 Sumter County Health Dept. 208 Rucker Street Americus, GA 31709 1:00 p.m. - 3:30 p.m. Maria Alegria
April15, 1996 Custer Terrace Comm. Life Ctr. Building #10800 Fort Benning, GA 31905 2:00 p.m. - 4:00 p.m. MSG Sargent Sanks
OR-16

April 15, 1996 Baker Village Rental Office & Community Room 1333 Benning Drive Fort Benning, GA 31905 9:00a.m. -11:00 a.m. Ava Shiver
April15, 1996 Health & Human Service Bldg. Columbus Health Department 2100 Corner Avenue Columbus, GA 31902-2299 2:00 p.m. - 4:00 p.m. AmieHardin
April 19, 1996 Hanson Drive Community Room 113 Hanson Drive Americus, GA 31709 12:30 p.m. - 4:00 p.m. Suzanne Baily
Valdosta 8-1 April16, 1996 Lowndes County Health Dept. Human Resource Building 206 South Patterson Street Valdosta, GA 31601 2:00 p.m. - 4:00 p.m. Janet McClure
Albany 8-2 April12, 1996 MCLB Boyette Village 1701 Georgia Avenue Albany, GA 31705 3:00 p.m. - 5:00 p.m. Nathalie DeLannoy
April15, 1996 Dennis Homes (Harambee Head Start Center) 630 Tulsa Lane Albany, GA 31705 9:00 a.m. - 10:00 a.m. & 6:00p.m.- 7:00p.m. Janice Newberry

GA WIC PROCEDURES MANUAL FY'97

Attachment OR-7 cont'd

April 17, 1996 Decatur County Health Department 928 West Street Bainbridge, GA 31717 3:00 p.m. - 5:00 p.m. Sheila White
April 18, 1996 Colquitt County Health Department 214 W. Central Avenue Moultrie, GA 31776 3:00 p.m. - 5:00 p.m. Sherrie Stubbs
April 18, 1996 Thomas County Health Department 440 Smith Avenue Thomasville, GA 31792 3:00 p.m. - 5:00 p.m. Nancy Jeffery
Savannah 9-1 April 16, 1996 Chatham County Health Department Midtown Site 1602 Drayton Street Savannah, GA 31401 10:00 a.m.- 12:00 p.m. Pat Jackson
April 17, 1996 Chatham County Health Department 20ll Eisenhower Drive Nursing Assembly Room Savannah, Georgia 31416 10:00 a.m.- 12:00 p.m. Pat Jackson

(MILITARY ONLY)

Waycross 9-2 April 15, 1996 Cracker Williams Recreation Center 245 East Bay Street Jesup, GA 31545 5:00p.m. -7:00p.m. Susan Horne
April 19, 1996 Waycross Housing Center Tebeau Street Waycross, GA 31501 10:00 a.m.- 12:00 p.m. Susan Horne
Brunswick 9-3 April 16, 1996 Altama Health Center Public Housing Project Site 2911 Altama Avenue Brunswick, GA 31520 10:00 a.m.- 11:30 a.m. Jo Manning
April 18, 1996 Liberty Co. Mental Health Ctr. Conference Room Oglethorpe Highway Hinesville, GA 31313 10:00 a.m.- 11:30 a.m. Jo Manning Athens 10-0 April 15, 1996 Athens Regional Library 2025 Baxter Street Athens, GA 30606 10:00 a.m. -11:00 a.m. Kim Kegel

April 17,1996 Elbert County Library 345 Heard Street Elberton, GA 30635 10:00 a.m. -II:OO a.m. Kim Kegel
April 18, 1996 Holiday Inn 2080 Eatonton Road Madison, GA 30560 3:00 p.m. - 4:30 p.m. Kim Kegel
April 19, 1996 Teen Scene 809-B Stower Street Monroe, GA 30655 10:00 a.m.- 11:00 a.m. Kim Kegel
Southside ll-0 April 17, 1996 Southside Healthcare, Inc. 1039 Ridge Avenue, SW Atlanta, GA 30315 2:00 p.m. - 3:00 p.m. Laverne Montgomery
Grady 12-0 April 17, 1996 Grady Hospital Room B-206 80 Butler Street, S.E. Atlanta, GA 30335 12:00 p.m.- 2:00 p.m. Lisa Stillman

OR-17

TABLE OF CONTENTS Page
I. General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-1 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. Identification of Person Picking Up Vouchers ......................... FD-3 C. Corrections .................................................... FD-3 D. Bi-Monthly Issuance ............................................ FD-3 E. Categorically Ineligible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-4 F. Issuance ofVouchers to Family Members ............................ FD-4 IV. Computer Printed Vouchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-4 A. Data Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-4 B. Voucher Cycles ................................................. FD-5 C. Voucher Packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-6 D. Voucher Shipments .............................................. Fp-10 E. Receipt of Vouchers ............................................. FD-1 0 F. Inventory Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-10 G. Issuance of Computer Printed Vouchers ............................. FD-1 0

Page

V. Manual Vouchers ................................................... FD-13

A. Blank Manual Vouchers .......................................... FD-14

B. Preprinted Manual Vouchers or Special Manual Vouchers . . . . . . . . . . . . . . . FD-14

C. Ordering Manual Vouchers ....................................... FD-14

D. Receipt of Manual Vouchers ...................................... FD-15

E. Inventory Control of Manual Vouchers .............................. FD-15

F. Issuance of Manual Vouchers ...................................... FD-16

G. Distribution of Manual Voucher Copies ............................. FD-19

VI. Georgia WIC Program Identification (ID) Card .................... ....... FD-20

VII. VIII.

A. General ....................................................... FD-20 B. Required Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-20 C. Participant Instructions ........................................... FD-21 Proxies ........................................................... FD-21 A. General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-21 B. Reasons for Proxies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-22 C. Authorization .................................................. FD-22 D. Voucher Pick Up, Issuance, and Use ................................ FD-22 E. Restrictions .................................................... FD-23 F. Participant Instructions ........................................... FD-23 Mailing WIC Vouchers/Delivery ofWIC Vouchers . . . . . . . . . . . . . . . . . . . . . . . . FD-23 A. Conditions for Mailing/Delivering Vouchers .......................... FD-23 B. Acceptable Reasons for Mailing/Delivering Vouchers . . . . . . . . . . . . . . . . . . FD-24 C. Reasons for Mailing/Delivering Vouchers (Mass Mailing) . . . . . . . . . . . . . . . FD-24 D. Mailing Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-25 E. Vouchers Mailing Process ........................................ FD-25 F. Returned Vouchers .............................................. FD-26

IX.
X. XI. XII. XIII.
XIV.
~.,
XVI. XVII. XVIII. XIX.
XX.

Page G. Replacement ofailed WIC Vouchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-26 H. Monthly Report ................................................ FD-26 Voided Vouchers ................................................... FD-27 A. Voided Computer Manual Vouchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-27 B. Voided Manual Vouchers ......................................... FD-28 Transporting Vouchers ............................................... FD-28 Prorated Vouchers .................................................. FD-28 Late Pick-Up of Vouchers ............................................ FD-30 Security ofissuance Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-31 A. WIC Vouchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-31 B. WIC Program Stamps ............................................ FD-31 C. VOC Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-31 D. Voucher Register . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-31 Redemption of WIC Vouchers ......................................... FD-31 A. General ....................................................... FD-31 B. Checkout ....................................... .' .............. FD-32 C. Cashier Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-32 D. Voucher Redemption and Signatures ................................ FD-32
-B2~,::~J~&i!?~~S.q~~~!9~f&f:'\M:~!!~~~iiftt"i~::'I!EnTI::::::E:m1'i:n:.mI::Ii:'[:sj';:-::'m~(:.,.;r1?32,3 1\Jl :g~~~gs~~t!!:'3~I':?l~ifgfT:fE:fii?. 2!:m:~:I1.?::':1':0:i:m:::sc::!;;:;';::FfEni:0:1!02!822%,;':: ?1'E'm:;r!2:12:~
. ?.~ Q[.2~~::~t~~r2>:~$.I&2~tllxfiR~Igl2l~I~m:~~m'~ffiP.@~tt:sml::mw;;Mnn;Im:: ::':.:;rJ.2:w~
g ~2!!91.!~1.:.~9.:~t:~9!~!!l.'iPi'r!?~~~~ngfl9':l~~~:~l:tt 1f!\,l]ill@f'lit::m::mm.mn~1m::.::'T.t:Qia1 B'f ~!1~!1%EtiD:~;~]!@ffiTI@11ti:t:Mm::::ili1:1m1%0i:::::ntE:1'.';lliili0:11::,'.mt1::':@::::::rf1Ili1EElB=:H:?I::~R:9l
Automated Special Manual Voucher System . . . . . . . . . . . . . . . . . . ; . . . . . . . . . . . FD-36 Automated Special Manual Voucher System Equipment . . . . . . . . . . . . . . . . . . . . FD-36 Establishing Clinics/Clinic Changes ....................................FD-37 Borrowed Vouchers ................................................. FD-38 Cumulative Unmatched Redemption Report (CUR) . . . . . . . . . . . . . . . . . . . . . . . . FD-38 A. Introduction ................................................... FD-38
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u: ~@.~U:tt~~s9ae~~rum.\1~1~!1Jgmn0fwli:m:;l:::::mr::mm;s0Ei:i_::::=::=i'Il.tw!:':mm1,.1\t::;:;rf!IJ;~
~~ ~~~~:1!1~';f1.9!li;S:~9f!t<&nEJi]ili0:[-ii'!Ii=1:%ifiii;1;;:::IrE1':E:If:IJ100f::mim==r:IEEii0!:::;_:::::i.WEl Attachments: ' FD-1 Computer Printed Voucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-43 FD-2 Blank Manual Voucher ......................................... FD-44 FD-3 Preprinted Standard Manual Voucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-45 FD-4 Automated Special Manual Voucher .............................. FD-46 FD-5 Voucher Create Calendar ....................................... FD-47 FD-6 Voucher Cycle Packing List ..................................... FD-48 FD-7 Computer Printed Voucher Register ............................... FD-49 FD-8 Voucher Register Summary Page ................................. FD-50 FD-9 Transmittal Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-51 FD-1 0 Form and Manual Voucher Orders ............................... FD-52 FD-11 Manual Voucher Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-53 FD-12 Batch Control Form ........................................... FD-54 FD-13 Batch Control Exception Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FD-55 FD-14 Georgia WIC Program Identification Card ......................... FD-56 FD-15 Request to Establish New Clinic/Clinic Changes .................... FD-57 FD-16 Daily Roster/Monthly Mailed Voucher Report ...................... FD-58 FD-17 Borrow Voucher Report Form .................................. FD- 59 FD-18 Cumulative Unmatched Redemptions Part I ........................ FD-60 FD-19 Cumulative Unmatched Redemptions Part II . . . . . . . . . . . . . . . . . . . . . . . FD-61 .!?:E~QI:9,~t2!U~:~~~f91~-cm~~'R:~!'B~I111t:R111ilitt~!iltt!Mi:uif:1;::;;:;miBn~

GA WIC PROCEDURES MANUAL FY '97
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 proxies, on a monthly or bimonthly 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, medical/nutritional, 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 tapes. Also, several local agencies are using the ATVS (Automated TadNoucher System) or MVS (Manual Voucher System) developed by the State WIC Office to create vouchers and prepare automated turnaround documents. Both the vouchers and turnaround documents (TADs) are submitted to the ADP contractors via modem. These local agencies only receive computer generated TADs under the following conditions: Automated Termination Action, Automatic Update oflnfant to Child, and Transfers IN or OUT of clinic.
Computer generated vouchers for each participant are printed by the ADP Contractor and sent to the appropriate clinic or district/local 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-1

GA WIC PROCEDURES MANUAL FY '97
IT. 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-1) 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 of late 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 staffat the time ofissuance. (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 fiils~ea sets of four (4) food package types.
These vouchers contain a preprlht~d':~ttfud~d food package (Attachment FD-3).
Standard voucher sets should not be broken to issue single standard vouchers. The four (4) types of food packages available are:
1. Infants (Food Package 113). 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 '97
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). ::Qiesi~
Y.~!BP~.i~i"'+~TR~~:!2&~~4;t~:i91:J~tiR~f-[I1'\t~IJ,tC?ryIog::::\V~@ii1fiy~'f~f~x~,jgf
t~e~~Ii.t!
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 ID card for signatures ofparticipant/proxy. If a proxy is picking up the vouchers, his/her signature must be on the ID card. If a participant has not previously had a proxy sign their ID card, the proxy must have a dated note, signed by the participant/parent/ guardian/caretaker, giving him/her the authority to pick up vouchers for the participant. The proxy/authorized representative must also present some form of identification to verify that he/she is the person authorized by the participant to pick up vouchers. If a participant/parent/guardian/caretaker does not possess, or has lost his/her ID card, other identification may be accepted as verification and a new ID card issued. 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-IX., "Voided Vouchers"). 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 '97
E. Categorically Ineligible
Categorically ineligible refers to the period oftime 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 who have reached their 1st birthday, children who reach their 5th birthdate, 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 ofsuspected fraud or abuse, immediate termination is in order.
A full set of vouchers must be issued when a client becomes categorically ineligible before the end of the 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 of vouchers 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 ofVouchers 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:
1. District/Unit/Clinic. The district is represented by a two-digit number, the unit by a one-digit number, and the clinic by a three-digit number.
FD-4

GA WIC PROCEDURES MANUAL FY '97 2. WIC II!> Number. The participant's unique identification number which corresponds to the number on the TAD. Self-Check Digit. Calculated by the ADP Contractor. 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 Bank.
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. ~~~W.M~~~~~~t!C.~i:',\mA~"~~PP~!f~~,Rfi:~"JP~}P:9:t1~*9~c.t\:tffi~
amount .... ... ~ . .....-:.;.:..:''
~i:@:~?~~~5.t.;~~~.:-:~~!~t)@[I;i~,:;}~~ii>~!?i?!91'X~1Wf.l~!:!;~i~9!~:Y! tm~:m?~~1:'!i~~im~:iY9Hs[cmJJt~fJs~IF:.~914!:~'-~'x~&q9ri The reverse side of the computer printed vouchers contains an area' for endorsement by the authorized WIC vendor. B. Voucher Cycles
FD-5

GA WIC PROCEDURES MANUAL FY '97
The voucher pickup day is detennined by the clinic staffand 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 the next printing of the selected voucher cycle is dependent upon the time of submission of the 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 reports twice a month. The first cycle of vouchers (cycle 1) 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, orB or the one with the lowest Participant ID Number (usually #1).
1. The following items will be included in each clinic package (or clinic package #1 if there is more than one [1]):
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 ofthe Computer Voucher Register that accompany the clinic's computer printed vouchers. Two copies of the packing list are provided in order that the clinic may retain one copy and send one signed copy to the district/unit as acknowledgment of receipt of the vouchers.
b. Computer Printed Voucher Register (Attachment FD-7)
FD-6

GA WIC PROCEDURES MANUAL FY '97

Purpose - To provide a listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification ofreceipt ofvouchers. The register is organized in the same order as the computer generated vouchers.

Distribution -

Clinic District/Unit State

1 copy 1 copy, Summary 1 microfiche copy

Frequency - twice each month, with each voucher cycle

Sequence - District/Unit, clinic, Site Code, alphabetic by name oflead family member.

Register Description -

Line 1

WIC ID: 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 of their 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 ofthe 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

FD-7

GA WIC PROCEDURES MANUAL FY '97
SiGNATURE OF PARTICIPANT: Space for participant/ proxy signature.
DATE: Space for the date vouchers are picked up. The date 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 determined to be unclaimed.
Line2
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 information 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.
RECERTDUE-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-five (45) days from the EDC.
FD-8

GA WIC PROCEDURES MANUAL FY '97
RECERTOVDUE-~DYY
For breastfeeding women and children, subsequent certification is overdue based on the certification date plus six (6) months.
RECERT OVDUE (P) - ~DYY For pregnant women, subsequent certification is overdue based on the EDC plus forty-five (45) days.
1ST BDATE- WviDDYY Infant's birthdate is in the month after voucher issue month. Date printed is birthdate.
CATEG TERM- ~DYY 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
FORB -Delivery Date plus 12 months
FOR C - At 5th birthday
ISSUE DATE: The date of issue printed on vouchers.
2. The District/Unit 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 District/Unit to ensure that each clinic reports acknowledgment 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 District/Unit.
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GA WIC PROCEDURES MANUAL FY '97
(3) Total number of messages by message type.
(4) Signature line and certifying statement ofpersons closing out the voucher register, two signatures are required to closeout the 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.~ and are received by local agencies on the 22nd day of the month for the next month's cycle 1 and on the 7th day of the 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 and dated to verify receipt. A copy ofthe signed!dated packing list must be mailed to the local agency/district office within !IY~~3.~ days
ofreceipt ofthe vouchers. The original must be retained by the clinic for three (3)
years plus the current Federal Fiscal Year.
If a shipment is not received by the expected arrival date or the shipment is 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%) verification 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
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:
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GA WIC PROCEDURES MANUAL FY '97
1. Identification. Verify the identity ofthe person picking up vouchers. Please refer to page FD-III.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 ID card. The names must be identical.
The following items must be completed on the computer voucher register each time vouchers are issued:
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. This signature must match the signature of the participant or proxy on the ID card. The signature must be secured next to each set ofvouchers received OR the recipient must sign next to the first set of vouchers received and enter his/her 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 staff person enters his/her 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" and initial ~
(late the appropriate line(s). "Failed to sign" may not be
abbreviated.
(3) During a monitoring review, if one (1) percent or more of
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GA WIC PROCEDURES MANUAL FY '97
"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 staff will 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. If the 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 ditto marks (") may be used to indicate the date on subsequent lines. The date must be entered when vouchers are VOIDED also.
c. Clerk Initial. The staff person must initial here when vouchers are issued, voided. When issuing vouchers, the staff person must initial after the participant/proxy signs, but before vouchers are issued.
3. Voucher Participant/Proxy 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 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 form 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.
FD-12

GA WIC PROCEDURES MANUAL FY '97 The following procedure must be followed:
a. Acopy 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 rHer to FD-IV.G for instructions.
b. When the 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) ofthis copy ofthe 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 (Le. common site of employment or established "satellite clinic.")
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. Mailing/Delivery ofWIC Vouchers (See FD-VIII)
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:
2. All manual vouchers require completion of participant and issue data.
3. Blank manual vouchers require an additional entry of food quantities.
4. Automated Special Manual Voucher for on-site manual voucher printing.
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GA WIC PROCEDURES MANUAL FY '97
(Refer to FD-XVII.A. for more information on these vouchers.)
A. Blank Manual Vouchers
Blank manual vouchers are issued for the following reasons:
I. 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. If a 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)
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
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GA WIC PROCEDURES MANUAL FY '97
Local agencies must order manual vouchers from the ADP Contractor. Orders must be made using the "Form and Manual Voucher Orders" Form (Attachment FD-10) and must be received by the ADP Contractor by the 1Oth or 25th of each month. The ADP Contractor will fill manual voucher orders twice a month and will ship them with each cycle of computer printed vouchers.
D. Receipt of Manual Vouchers
1. Clinic
Clinics will compare beginning and ending voucher numbers to those on the Clinic Voucher Cycle Packing List. Any discrepancies must be reported to the ADP Contractor and the 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 ofthe vouchers. The original must be retained by the clinic for three (3) years plus the current Federal Fiscal Year.
2. District/Unit
The District/Unit receives a copy of each detailed clinic packing list for control, and a summary copy showing total vouchers received from the District/Unit. Any discrepancies must be reported to the ADP Contractor immediately. Missing shipments must also be reported to the State WIC Office.
E. Inventory Control of Manual Vouchers
When manual vouchers are received, the serial numbers must be recorded in the "Received" column ofthe "Manual Voucher Inventory" log (see Attachment FD11 ). This documentation must be completed the same day the vouchers are received by a responsible WIC person.

$!f~:I!:~.iiP,[~!i.I~~~~~!1m!I!~.~~R~~.f:~~.M~8'[1];~~~-Y2.!l~'1

Mg:i.fi:\\f!!!gili~!~~ii.~!P!!!t~!I!!i.i~g;!!!IJ.~!Y~!'~;!:9~!!9.~!~~i!~~!tfy.[~p~

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~..2~PJ~.!!!;:~,~r~!~~i'.!~g.!~l~f~!!~:~!P:~!~~~

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FD-15

GA WIC PROCEDURES MANUAL FY '97
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 ofManual Vouchers 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 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.
Bi-monthly issuance clinics may also issue a second set ofvouchers. 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
FD-16

GA WIC PROCEDURES MANUAL FY '97 pick up date.~
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 of issuance: 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
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. If blank 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 fo' ods, 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.ffl,
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GA WIC PROCEDURES MANUAL FY '97
"Signat)Jre ofParticipant 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 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 (1) 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 Thursday, etc.), if applicable in their clinic.
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GA WIC PROCEDURES MANUAL FY '97
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 if they 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 must be sent together to the ADP Contractor, but must be hatched separately. When sending via Express Mail, do not use a Post Office Box.
~~iiiil~!~~il~i1~il~l~l~illt~\~~~~~i~:i;i~
P.~iffim~g_:l~is~;th.~:~gtt~~Pr?Sr.!ti.~,f!.;~i.~.~-g-~)illf~hij~ti~ptq.9J:~ &QE:
Qg~!.fite
3. 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 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 ID 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.
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GA WIC PROCEDURES MANUAL FY '97
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 an) CARD
A. General
A Georgia WIC Program Identification (ID) card (Attachment FD-14) must be completed and issued, during the certification appointment, to any person who is enrolled in the Program. An ID 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 ID 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 ID card.
At each voucher pickup the ID card or another form of valid identification must be checked before vouchers are issued. The ID 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/guardian/caretaker does not possess, or has lost his/her ID card, other identification may be acceptable as verification and a new ID 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 ID card.
FRONT: 1. Participant's name 2. WIC ID number 3. Date certification period expires 4. Participant/parent/guardian/caretaker's signature 5. EDC date 6. Signature ofproxy(s), if the 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 participant/parent/
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GA WIC PROCEDURES MANUAL FY '97
guardianf. caretaker after he/she has left the clinic.
It is recommended that all of the information on the back of the ID card be completed.
BACK: 1. Appointment information 2. Voucher pickup code 3. Voucher interval code 4. Comments 5. Clinic identifying information 6. Q~'R.:~!~ii!!H~'NI@~t,
C. Participant Instructions
Participants/parents/guardians/caretakers must receive an explanation of the instructions on the purpose and use ofthe ID card. The following is a guide to the information that should be given to the participant regarding the WIC ID Card. Whenever possible, the participant's proxy(s) should be present during the explanation.
1. The ID card is to identify you as an authorized WIC participant when picking up and/or redeeming vouchers. Y.~ll.~l\"Q!iUfUce,'epWNQ'it~;lle~m:s :2@!ffi~ You must have your ID card when.piddliiup.voucher~i~"f>ehlg certified, or redeeming vouchers at the grocery store. A proxy must have the ID card to pick up or redeem vouchers. (Refer to section below for more information regarding proxies).
2. Notify the clinic if the ID card is lost or stolen.
3. Explain "Expiration Date" and when the participant will be due to be screened for eligibility again.
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
FD-21

GA WIC PROCEDURES MANUAL FY '97
certifications.,.in restricted situations (see Certification Section). A proxy should be a responsible person whom the participant/parent/ guardian/caretaker trusts and whenever possible, should be another person in the same household as the participant.
If a proxy picks up vouchers or brings a child in for subsequent certification, clinic staff must ensure that adequate measures are taken for the provision of nutrition education and health services to the participant.
B. Reasons for Proxies
Examples of reasons for designating a proxy include:
1. 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 parent/guardian/ caretaker. When a proxy is designated, the participant or parent/guardian/ caretaker must have the proxy sign his/her name in the designated space on the WIC ID card in their presence (refer to page FD-IV.G.2.a.(~) 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 unable to write):
1. 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).~:;;pp~
P.~~B!PID!f':~~ be informed at the initial certification appointment that thls."Is
their responsibility. Proxies must also be informed oftheir right to complain to the
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GA WIC PROCEDURES MANUAL FY '97 clinic about improper vendor practices.

E. Restrictions

1. Age. 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.

VIII. MAILING/DELIVERY OF WIC VOUCHERS

A. Conditions for Mailing/Delivering Vouchers

1. Vouchers may be mailed or otherwise delivered to participants on an individual hardship basis or in special circumstances, may be mailed in mass. If vouchers are mailed to a participant for hardship reasons, they will be mailed/delivered on a temporary/short-term basis. There should not be a standard, on-going reason (i.e. permanent difficulty accessing the clinic(s) for mailing/delivering vouchers to participants).

2. Vouchers must not be mailed in the following situations:

1. 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
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GA WIC PROCEDURES MANUAL FY '97
issuing WIC professional must obtain prior approval from the WIC Coordinator, and a copy ofthe page ofthe 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 of WIC Vouchers must be discontinued and the action documented.
B. Acceptable Reasons for Mailing/Delivering Vouchers
1. Difficulties of the participant and his/her proxy in obtaining vouchers for reasons such as illness.
2. Imminent or recent childbirth.
3. Appointments to pick up vouchers do not coincide with the print cycle.
4. Certification/Recertification 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 Mailing/Delivering Vouchers (MASS MAILINGS)
1. Environmental crisis as a result of a tornado, hurricane, flood snow storm, ice storm, exceedingly high heat f!l~_!gg~;"H~~
2. The participant receives their primary health care from a private physician and a second nutrition encounter (class or care plan) has been gg~~~
3. The participant does not have a clinic appointment or need follow-up and a second nutrition encounter (class or care plan) has been Sl.S~I~
4. The participant works during regular or extended operating hours, does not have a scheduled clinic appointment, does not need WIC follow-up ancf:~~
~i!9~Hffi~~!!!:~~9-1i~!!~~~~
5. The clinic will be closed for holiday or other appropriate reason.
NOTE: * Ifthe Food Stamp Program has discontinued or does not routinely
mail Food Stamps Coupons to a geographical location, WIC Vouchers can not be mailed to this area.
FD-24

GA WIC PROCEDURES MANUAL FY '97
* 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 vouchers 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 of 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).
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
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GA WIC PROCEDURES MANUAL FY '97
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 p~f~1 in an effort to issue. 1bis contact must be recorded in the client's record. If unable to contact, "void" the voucher(s) immediately and maintain on site until scheduled time that they are mailed to the bank, except manual vouchers which are returned to Data Processing.
Ifa record of manual voucher~ has been sent to tg'~:e;.:Q&ilfriilit{)r, manual
voilchers must be voided ancfsent 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).
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 ~Q)!WJ:i~m vouchers were mailed.
3. Number of vouchers issu;d"t~;Jplace 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,
FD-26

GA WIC PROCEDURES MANUAL FY '97
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
Voided vouchers should be marked "void" ifthe participant is ineligible for the vouchers
or if they are replaced with manual vouchers or if a participant does not pick up
vouchers by the last of the month. Vouchers marked VOID must be returned to contracted bank. Package the vouchers securely to prevent breakage and send them to the Contracted Bank by noon ofthe sixth (6th) workday ofthe following month.
A. Voided ComputerNouchers
1. 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,
(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 if the entire set of vouchers is voided. The word "void" may not be abbreviated. If less than an entire set is voided, the number(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 contracted bank by noon of the sixth (6th) workday of the following month. Never staple a voided voucher to any other voucher.
FD-27

GA WIC PROCEDURES MANUAL FY '97
(d) \Zoided vouchers must be securely stored according to program procedures (see FD-XIII) until they are forwarded to the ADP contractor.
B. Voided Manual 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 ifreturned unused by a participant.
I. Voided Manual Vouchers Which Were Reported to the ADP Contractor as Issued. 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 contracted bank. If the original is not available, the Lost/Stolen/Destroyed Voided Form must be used to report the void to the ADP Contractor.
2. Voided Manual Vouchers 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. ~
~9Is~.l!!!fq~~y~~19"!l~l!~5~!~!l~P;\~t@l~if~K:th1E~P:~,Q9:~~1f,~!g~, ..
X. TRANSPORTING VOUCHERS
The computer voucher register (when transporting vouchers) must be copied. The original voucher register must be left in the clinic. Once the participant signs the copied page, the copy must be attached to the original voucher register. The original computer voucher register must have the statement "See Attachment" gg~~l!}~g~~t~f:
XI. PRORATED VOUCHERS
The objective of prorated vouchers is to ensure that participants receive benefits for which they are entitled Jl~g:J~ valid time frame. Vouchers are issued based on the number of weeks within ~::ygriltedemption 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 of vouchers issued must be prorated.
FD-28

GA WIC PROCEDURES MANUAL FY '97

Prorating is the partial issuance ofvouchers by retrieving one or more vouchers from the designated voucher series. Vouchers ~g~' be prorated when:

(1) 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 damage/lost/stolen or destroyed, change in prescribed food package or agency error. Note: The procedures in Section FD-~ must be followed when replacing vouchers~

To ensure consistency when prorating vouchers the guidelines below must be followed.

I I Number of Dais Late

Women & Children

Less than 7 days late

I

full package

I

7-13 days late

I

3 vouchers issued (3/4 package)

I

14-20 days late

I

2 vouchers issued (Y2 package)

I

21-31 days late

I

1 voucher issued (114 oackage)

Infants

I

full package

I

full package

I

1 voucher issued (Y2) package

1 voucher issued (Y2 package)

ALTERNATE FOOD PACKAGES

I Number of Days Late I Less than 7 days late

Women & Children II

Infants

I

full package

I

full package

I

7 - 13 days late
I

6 vouchers issued

full package

(3/4 package)

I

I

14-20 days late
I

4 vouchers issued (Y2 package)

1 voucher issued (Y2 package)

I

21-31 days late

2 vouchers issued (1/4 package)

1 voucher issued (Y2 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 Either issue entire food package andfollow procedures noted above, or change the pickup code and submit to the ADP Contractor.

FD-29

GA WIC PROCEDURES MANUAL FY '97
XII. LATE PICK-UP OF VOUCHERS
Participants who are late picking up their vouchers must be issued a prorated food package 9~i~!E@.r~~9Jl.~!~Ji:H.:\l~~ Ifparticipants come in for their vouchers after
they have been returned to the.ADPCoritractor as "VOID", 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 bef>.ffi~l~g to reflect the period of time left until the participant's next scheduled pickup da.te.
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 beforethe "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.
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 p~9~l~ voucher issuance for late pickup follow procedures for prorating voucilefs:lt:!ltl!!
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 staffmust:
(1) documerit 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
FD-30

GA WIC PROCEDURES MANUAL FY '97
computer generated vouchers
(4) Give the participant an appointment for next month's pickup for the new pickup date.

XIV.

A. WIC Vouchers
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
I. 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.
D. Voucher Register
Voucher register must be stored separately from the vouchers in a locked location.
REDEMPTION OF WIC VOUCHERS
Participants/proxies exchange WIC vouchers for supplemental foods at participating 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 clinic) so that they fully understand their responsibilities regarding the use ofWIC vouchers.
A. General
I. Participants or their pf,g~!~ must p~gf;;!P.:~ WIC ID card. They do not need any other ID. (.~51'1rtD
2. It does not cost anything to use WIC vouchers. Under no circumstances will

FD-31

GA WIC PROCEDURES MANUAL FY '97 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 ~'fi[{?:!ffip!:~: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 signature(~). 2.
3. The types and quantities of food being purchased are the same as those
prescribed on the vouchers. 4. The vouchers have not been altered.
l!1!L~:;:&~!R~r~~~l!r.r:Imm~*!R~;Bl?PI~,,~!is~M?.!tl!liYe1!9.J~~EtPn~1'!9I!fs
P..,,,.a,.m,,""'c''r'''lta."n'''.'t"'t's'"\:S':>rX<'y~a;"t-*t"f~'t''e/'l'?''The ParticiPant!proxYwill countersign each voucher in the
cashier1s presence; Ifthe signature on the vouchers does not match the signature on the WIC ID card, the cashier may not accept the vouchers and must immediately notify the clinic ofthe situation. Participants must be instructed not to countersign until the cashier has written in the total cost ofthe foods. If a name has been signed in the counter signature block then the grocery store must obtain a signature above the presigned name.
FD-32

GA WIC PROCEDURES MANUAL FY '97 If the participant/proxy is unable to write, he/she must present the WIC ID 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.
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FD-33

GA WIC PROCEDURES MANUAL FY '97
*

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FD-34

GA WIC PROCEDURES MANUAL FY '97
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 1. Participant must return unused formula to the clinic if available, and/or 2. Return unredeemed voucher(s) to the clinic for voiding. 3. Supplemental vouchers issued must be prorated for the remainder of time in
the issuance period. 4. Document amount, type, and disposition of formula returned to clinic on
voucher ~egi~~r 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
FD-35

GA WIC PROCEDURES MANUAL FY '97 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 ~1i9_l:[q be returned to the company. Call the Office ofNutrition to request a return ofthe unopened cases of formula within seven (7) working days.

XVI. AUTOMATED SPECIAL MANUAL VOUCHER SYSTEM

An Automated Manual Voucher system is currentlytgijif@:J statewide. The computer is programmed to print the required vouchers, includliig'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.

XVII.

AUTOMATED SPECIAL MANUAL VOUCHER SYSTEM EQUIPMENT In order to participate in the Automated Manual Voucher System, ~~[.'rl!~t~)I~~g 2\!!~~![Y~~~'f~!Y.[;the equipment listed below must be putdh~ed:-- wm'ww---

Hardware

Operating System Speed RAM: Hard Drive: Monitor: Printer:

:t.?.JP~\9:!9..
1:oo:MHZ
:-::;:;:;:;:;... ;,.;,:~.;.;.:-:.::.:=:-;-;.:.
;tp_;:m~!Rm
2. .'. .0. .0. .'. .m. .e. .'~"J'\:t'. .~.-.a..o}:~:;,:e,.,s. .
VGA
24 Pin, wide carriage, dot matrix Okidata Microline 391
recommended

When WIC is incorporated into Health Outcomes and Services Tracking (HOST), then this hardware will become the WIC workstation(s), operating under the HOST file server.

Software: Operating System: Applications Software: Database library:
Network:

MSDOS or IB:MDOS 5.0 "C" Codebase - A third party library that provides data management and user interface tools

The LAN 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

FD-36

GA WIC PROCEDURES MANUAL FY '97
program development cost for the LAN version is $20,000. Hardware and nonapplication software costs are associated with HOST and are the responsibility ofthe State/County.
Conversion and maintenance if central processing authority plans to change application, operating or database management software.
In the event that changes ~ made to any of the software currently prescribed, it would probably only apply to HOST. Therefore, the ATVS would not be impacted, and could continue operating unchanged since it has no interfaces other than the WIC ADP Contractor which is limited to ASCII files. In the future when ATVS is integrated into HOST, 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.
XVIII. 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 change within sixty (60) days of the
date ~9-~iwhich 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:
1. 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 Clinic/Clinic Form within five (5) days from date ofrequest.
3. The Local Agency completes the form ~~~~*-~~J:@:~g~!:fQH?J and returns it to the'State WIC Office.
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.
FD-37

GA WIC PROCEDURES MANUAL FY '97

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 verify 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 WIC Office will make a site visit and provide technical assistance, consultation, and training to the Local Agency in start up procedures.

XIX.

BORROWED VOUCHERS

Vouchers may be borrowed within a District from one clinic by a clinic whose current stock is depleted.

Timeliness of form submission is important. Viking must be notified of all manual voucher reassignments as soon as possible. Any borrowed voucher reassignments not received by Viking before reconciliation (usually around the 8th working day of the month) may result in new check issues received from clinics being rejected because the issue clinic fails to match the check issue master file. Accordingly, any of these vouchers that were cashed would result in unmatched redemptions the first month and would be listed on the Cumulative Unmatched Redemptions Report if not corrected by the second month.

Those borrowed voucher reassignments that fail the required edits will also be subject to the unmatched redemption process described in the previous paragraph. If a borrowed voucher reassignment does fail the edits, the districts will be contacted to correct the discrepancy for the next reconciliation.

Viking will accept the new Borrowed Voucher Report input form from the districts, edit the required fields for validity, and reassign clinic numbers on the check issue master file on a monthly basis before reconciliation. Instructions for the use of borrowed vouchers may be found as Attachment 17 of the Food Delivery Section.

XX. CUMULATIVE UNMATCHED REDEMPTION REPORT (CUR)

A. Introduction

The Cumulative Unmatched Redemption (CUR) Report identifies redeemed manual vouchers, which have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report. The vouchers should be reconciled ~!l::E~!!~~!~Z281Uf.!.'Sf<?,!Aor a manual reconciliation should be performed Wi'tlt)!~(:)['~t~ ;wtG::;QJliq~, depending on how much time has elapsed since
the voucherwas.redeemeCi.-Jji~:~~~ar9r~!n.Y9.IP~3
FD-38

GA WIC PROCEDURES MANUAL FY '97
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FD-39

GA WIC PROCEDURES MANUAL FY '97
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FD-40

GA WIC PROCEDURES MANUAL FY '97

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FD-41

GA WIC PROCEDURES MANUAL FY '97 FD-42

GA WIC PROCEDURES MANUAL FY '97 COMPUTER PRINTED VOUCHER

Attachment FD-1

FD-43

GA WIC PROCEDURES MANUAL FY '97 BLANK MANUAL VOUCHER

Attachment FD-2

FD-44

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-3

~
PREPRINTED STANDARD MANUAL VOUCHER

FD-45

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-4

~
AUTOMATED SPECIAL MANUAL VOUCHER

FD-46

GA 'VIC PROCEDURES l\tiA1'tUAL FY '97

Attachment FD-5

1996

VOUCHER CREATE CALENDAR
GA Voucher Calendar

CYCLE 1 1st- 14th

1-Cycle 1 TAD INPUT CUTOFF (15th)

,-._.

2-Date Federal Express shipped VOUCHERS ARRIVE at 0/U (22ncf)

3-ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic

CYCLE 2 15th- Month end

4-Cycfe 2 TAD INPUT CUTOFF (last workday of each month) 5-Date Federal Express shipped VOUCHERS ARRIVE at 0/U (7th) 6-EST!MATED date UPS shipped VOUCHERS ARRIVE at Clinic

FD-47

1997
1 2 3 4
5
6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

GA WIC PROCEDURES :MANUAL FY '97

Attachment FD-6

VOUCHER CYCLE PACKING LIST

PAGEM REPORT ENCR2006

STATE OF GEORGIA WIC SYSTEM VOUCHER CYCLE PACKING LIST (CLINIC)
FOR THE SECOND CYCLE OF JULY

CLINIC PAGE 2 D/U/CL

DISTRIBUTION:

CLINIC KEEPS TOP COPY

CLINIC RETURN SECON COPY TO DISTRICT/UNIT

( ) VOUCHER REGISTER POS 1508- 1566

( )

COMPUTER PRINTED VOUCHER FROM 1006547 TO 1008499

IF THE ACTUAL CONTENTS OF THIS SHIPMENT DIFFER FROM THIS PACKING SLIP,
CONTACT EDS-WIC INUY1EDIATELY. TELEPHONE -1-800-221-9182.

CONTENTS VERIFICATION

WIC REPRESENTATIVE SIGNATURE

DATE

EDS SHIPPING USE

CONUv!ENTS

NUMBER OF PIECES THIS DISTRICT/UNIT - - - - - - - -

EDS QUALITY CONTROL INITIALS - - - - - - - - - - -

FD-48

GA WIC PROCEDURES MAJ.~UAL FY '97

Attachment FD-7

COMPUTER PRINTED VOUCHER REGISTER

n.l.::: or ~ 1CIC: nnn
C:Ot<Z"...JJ. ~ ~ U::IS':tt

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FD-49

GA WIC PROCEDURES MAi'WAL FY '97

Attachment FD-8

VOUCHER REGISTER SUMMARY PAGE

PAGE 708 REPORT EWCR201G

STATE OF GEORGIA WIC SYSTEM COMPUTER GE,..,"ERATED VOUCHER REGISTER

DISIUT 01-1 RUN DATE 12118/91 INPUT CUTOFF DATE 12113/91

DIU- 01-1

TOTAL OF 3,639 PARTICIPA."'TS RECEIVING

12,809 VOUCHERS

FOR 01/92

TOTAL OF 3,374 PARTICIPA."'TS RECEIVING

11,913 VOUCHERS

FOR 02/92

MESSAGE TOTALS 1496 RECERT DUE- MMJDDIYY

(DUE FOR RECERT- SEE CERT-DUE)

214 CATG TER"I- MMJDDIYY

(CATEGORICAL TER"I DUE ON DATE SHOWN)

919 l'clJTRITIONAL ASSESS;o..IENT-MMIDDIYY

(NUTRITIONAL ASSESSEMTN DUE- DATE SHOWN)

162 1ST BDATE- MMJDDIYY

(lNFA."'T TO CHlLD CHA."''GE IN DATE SHOWN)

226 RECERT DUE (P) -l\-1;\l/DDIYY

(PASSED CERT-DUE DATE)

0 NO-SHOW PRIOR NO- MM

(CLIENT DID NOT PICK UP COUCBER IN MONTH)

72 RECERT OVDtJE (P)- M;\l/DDIYY

(PASSED CERT-DUE-DATE P)

0

RECERT OVDUE (F2)- MMIDDIYY

(PASSED CERT-DUE-DATE PRIORITY 2)

0

RECERT DUE (PRI2)- ~1;\1/DDIYY

(DUE FOR RECERT (PRI-W) SEE CERT DUE)

FD-50

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-9

TRANSMITTAL FORM

Verification Receipt ofWIC Vouchers

Client's Name

Clinic---------------

This is to certify that I received the following WIC vouchers:

#___________________________ #_____________________________

#_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ #________________________________

Participant/Proxy

Date

Staff/Initials

Date

Verification

Receipt ofWIC Vouchers

Client's Name

Clinic---------------

This is to certify that I received the following WIC vouchers:

#_____________________________ #_________________________________

#__________________________________ #_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Participant/Proxy

Date

Staff/Initials

Date

Verification

Receipt ofWIC Vouchers

Client's Name

Clinic----------------

This is to certify that I received the following WIC vouchers:

#_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ #_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

#_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ #_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Participant/Proxy

Date

Staff/Initials

Date

Verification

Receipt ofWIC Vouchers

Client's Name

Clinic------------------

This is to certify that I received the following WIC vouchers:

#____________________________ #________________________________

#__________________________________
#----~---------------------------

Participant/Proxy

Date

Staff/Initials

Date

Verification

Receipt ofWIC Vouchers

Client's Name

Clinic--------------------=

This is to certify that I received the following WIC vouchers:

#_________________________________ #___________________________________

#____________________________________ #_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Participant/Proxy

Date

Staff/Initials

Date

FD-51

GA WIC PROCEDURES MANUAL FY '97 FORM AND MANUAL VOUCHER ORDERS

Attachment FD-1 0

Return to:

Viking Computing, Inc. 1000 North Madison Ave., Suite W-11 Greenwood, Indiana 46142

Phone: 1-800-899-7913 FAX: 1-317-889-9485

Your District/Unit: Clinic name: Address:
Contact person:

This order is for clinic #: - - - - _ _ _ _ _ _ _ _ _ _ _ _ Phone: _ _ _ _ _ _......:. DateMailed: _ _ __

NOTE:

Viking processes Georgia WIC Program orders twice a month. Orders received at Viking by the lOth of the month are processed so that the order is delivered by the 25th of the month. Orders received at Viking by the 25th of the month are processed so that the order is delivered by the lOth of the following month. If the 19th,or 25th fall on the weekend or holiday, the cut-off is the workday before.

MANUAL VOUCHER ORDER

BLANK MANUAL VOUCHERS FOR HAND COMPLETION

Blank manual voucher (no tuna or carrots) 408 (blank manual voucher with tuna and carrots)

PREPRINTED MANUAL VOUCHER PACKAGE SETS FOR HAND COMPLETION

Sets of prenatallbreastfeeding women package 404 Sets of postpartum non-breastfeeding women package 502 Sets of infant package 113 Sets of child package 603

SPECIAL MANUAL VOUCHERS FOR USE ON COMPUTER

Special manual vouchers for use on computer (ATVS, MVS, M&M, or other State appoved system)

CERTIFICATION FORM <TAD) ORDER

Blank TAD (no preprinted ID number) Prenumbered TAD (preprinted ID number)

OTHER FORMS

Form and Manual Voucher Supply Order forms Lost/Stolen/Destroyed voided Voucher Report forms Vendor Input Form

FD-52

GA WIC PROCEDURES MANUAL FY '97 MANUAL VOUCHER INVENTORY

Attachment FD-11

STANDARD MANUAL _ _ _ __

MANUAL VOUCHER INVENTORY CLINIC _ _ __

BALANCE BROUGHT FORWARD----

DATE

RECEIVING NO. ENDING NO. NO. RECEIVED NO. ISSUED

NO. VOID NO. ONHAND INITIALS

'
FD-53

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-12

BATCH CONTROL FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

DISTRICT/UNIT

CLINIC

BATCH CONTROL FORM

DATE

NUMBER

I I

I I

INSTRUCTIONS
VIKING INPUT SECTION
COMMENTS:

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUEDNOIDED MANUAL VOUCHERS.

2. DO NOT BATCH TADS WITH MANUAL VOUCHERS

3. DO NOT SUBMIT VOIDED/UNCLAIMED COMPUTER VOUCHERS TO VIKING.

4. SUBMIT THE 1ST AND 2ND COPIES OF THIS FORM AND ACCOMPANYING MATERIALS TO:

VIKING COMPUTING, INC. P.O. BOX 2504 GREENWOOD, IN 46142-2504

5. RETAIN THE 3RD COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS OR MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT

NUMBER IN BATCH

TURNAROUND

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

DATE SENT BY DISTRICf/UNIT DATE RECEIVED AT VIKING
FORM 3762(REV.02-92)

PREPARER'S SIGNATURE SIGNATURE
FD-54

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-13

BATCH CONTROL EXCEPTION REPORT

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

DISTRICT/UNIT

CLINIC

VOUCHER BATCH EXCEPTION FORM

DATE

NUMBER

TIDS FORM HAS BEEN GENERATES AS A RESULT OF:
THE QUANTITY ON THE CLINIC COMPLETED BATCH CONTROL FORM DOES NOT AGREE WIT THE ACTUAL QUANTITY RECEIVED.
THE VOUCHERS WERE RECEIVED IN A BATCH OF TADS.
ONLY ONE (1) COPY OF THE BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.
NO BATCH CONTROL FOR!'\1 WAS RECEIVED WITH THE VOUCHERS.

VIKING INPUT SECTION

TYPE OF DOCUMENT
ISSUED MANUAL VOUCHERS VOIDED :MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

' DATE BATCH RECEIVED AT
FD-55

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-14

GEORGIA WIC PROGRAM IDENTIFICATION CARD

19.. STATE OF GEORGIA

Ocptnmcm o( lhuntft kc~nn

o

Diwiiotl ot "'blic Jlullh

~

YttC PROOIWA tOEHIIFIC.UtOII C.UtO

MOl VN.O \llfi)IOur
"'e
'"I"I,I'I".U','."

~AIUICII'AHfS
10 ""'"'
" ' " ' " " ID' t tf.U.t " ' " ' " " 10 I HAW( ""''""''""'"J IOJre.Ulf
10 H.ulf
I1II I II I II

'" Ill'.
0&11 -!!!!....

Olt!NG TillS FOLDER EVERY VISIT APPOINTMENTS -..uC&AWf
..".-,".I..".',C,Q.li.UIIIC
Io_...c..,,.,.<...r --f-- ------- ---
--!- --1---t---t--

"""'""""" - - - 'f'O.ICiot"llfiiiN.t4CCOC: _ __
~..c"'' - - - - - , - - - - - - - - -

.. ,... liltiNG TillS t'OI.DEI\ EVI:I\Y VISIT
, ,,..,.. ,

FD-56

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-15

REQUEST TO ESTABLISH NEW CLINIC/CLINIC CHANGES

GEORGIA WIC PROGRAM REQUEST TO ESTABLISH NEWCUNJC/O..!NICCHANGES

PURPOSE OF REQUEST

EST. NEW O..INIC

EfFECTIVE DATE OF CHANG~E:o__ _ _ _ __

QINICOiANGE - - - - -

TYPE OF CHANGE~-----------------------------

DISTJt.JNIT - - - - - -

DATESUBMniTED~---------------

COUNTY# - - - - - - CONTAcrPERSON NEWO.INIC NAME

COORDINATOR-----------------
.

MAIUNGADDRESS (NOT P.O. SOX)

PHONE#

ATTENTiON:

O.INIC DAYS AND HOURS OF OPERATION PURPOSE OF fRO POSED CUNIC (~irc.!e) ~crtifi~atioc rert.ifi~atioc ccltitioc edccatioc vou~h~ isnuce

other (spc~ify) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
SCHEDUlE OF VOUCHER ISSUANCE (cir.:le) mo11thly bi-t:~onthly O<ld bi-monthly even

PLEASE INDICATE IFTADS AND VOUCHERS ARE TOe: !H!PPED TO ANOTHER LOCATION entER TIV.l-< THIS O.!NIC

VOUOiER ORDERS SPEOAt VOUCHERS BLANK VOUOiERS

TAD ORDERS BtANKTADS PREPRINTED TAOS

WOMEN (P&B)

l PREPRINTED VOUCHER PAO<AGES PACXA.GES WOMEN (N)

-----------~PACKA<

INFAI'ITS

---------.....:PACXA.GES Oi!LDR.S'<

----------PACKA<

PlEASE INDICA."IE A BEGINNING TAD NUMBER (EXAMPLE: a.JNIC #123 WOULD BE 123000001 FOR THE BEGINNING TAD NUMBER)

Vti:IH<; WIU.ASSICH A MAXIMUM HUMBER. OF INDIVIDUAL. VOUCHE!tSTO BE 1R.IHTED. nus HUMBER wtU.

EQUATE TOIOO PAC%AC~ FOR. WOMEN,lOO 1ACXAC~ FOR. INFANTS A.'IO I001AC!CAG~FOR CHILDREN..

II' YOU WISH TO INCREASE THIS HUMBER, Pt.EASE IHOIOI.TE..

"\'ES___

NO_ __

FD-57

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-16

DAILY ROST~R!MONTHLY MAILED VOUCHER REPORT

Participant's Name

LD.

Number of

Number Vouchers Issued

Number of Vouchers Returned

Signature of CPA

Date

Replaced Voucher Redemption Value

Returned Numbers Lost/Stolen of lost Vouchers

' D

A

I

L y

EndofMonth Total#of

Totals

Participants:

Date:

Total # Issued:

Total# Returned:

*Redemption Rate must be completd by the District Office.

Total # Replaced:

Total Redemption lvatue: $

FD-58

GA WIC PROCEDURES MANUAL FY '97 BORROWEDVOUCHERREPORTFORM

Attachment FD-17

.

GEORGIA DEPARTMENT OF

HUMAN RESOURCES

WIC PROGRAM

SORROWED VOUCHER REPORT

I I I I BORROWING DISTRICT/UNIT:

I I I I CLINIC:

DATE:

INSTRUCTIONS

-- USE THIS FORM TO REPORT MANUAL VOUCHERS SORROWED FROM ANOTHER CLINIC.
RETURN TO VIKING AS SOON AS POSSIBLE.

MAIL TO:

VIK!~'<:; q:>MPUTING. INC

'

GEORGIA WIC UNIT

1000 N. MAOISON AVENUE. SUITE W-11

- OR FAX TO:

GREENWOOO,IN 46142 (Jt7J ea9-9485

LENDING OISTRICT(S) CUNIC(S)

V 0 U C H E R R A N G E (S)

BEGINNING VOUCHER NO.

ENDING VOUCHER NO.

QUANTITY

I ~ I Jl l l l I I I I I I I I I I I l f I l__j__L_j I I ! j__J _j

I I I II I I II I I I I 1 I I II I f I I I I I II 1 I I I I

' ' I

II I I II I I 1 I I I I I I I I I I 1 I I I I I I I I I

I

I

I

I1 I

l

I I

I

I

I 1I

I
I

1 II

I

I I

I

i

I

I

I I

I

I

I

I

I

--. I I I I I I I I I I f I I I I I I I I I I I l I I I I I I I I I
I I I II I I II I I I I I I I II I I I I I I I I I I I I l I

I I I II I I II I I l I I I I II I I I I I l I II l l I I I

I I l II I f II I I I I I l I II l I I 1 I I I II I l I I I

I I I I I I I I I I I' 1 I I I I I I I ! ! ! I I 1 I l I 1 I 1 I

I I I lI I I ll I I I I I I l II I I I I I I I II I I I I l I I l II I I II I I I I l I I I I I I I I I I I I I I I I . I I

I I I II ! ! II I I I
REASON(S):
0 0 INSUFFICIENT QUANTITY ORDERED .. COMMENTS:
.

I I I I II
ORDERED LATE
.

I I I ! I I I II I I I I I

0

0 ~
ORDER NOT RECEIVED FROM VIKING

On-tER

~
.

.

'

OISTR!CT OfFICE APPROV& OATE

'W<ING WHITE COf'Y

SNO YEJ..CNI COPY

OfSTfUCT CM'ACE PINK COf'Y

ATIACHMENT G10

CUNIC GOlD COf'Y

- ..

FD-59

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-18

CUMULATIVE UNMATCHED REDEMPTIONS PART I EXAMPLE

PAGE REPORT EWRR350G ' COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF MARCH

1996

PART 1 NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE FEBRUARY JANUARY NUMBER NUMBER S AMOUNT S AMOUNT

74622188 36698524 R 66.36 74623694 36614713 R 39.75 74623736 55658120 R 36.15 74623812 36551839 R 4.77

TOTAL

147.03

***** STATUS *****

VOID

REDEEMED

4

TOTAL

4

0

CLINIC PAGE D/U/CL 01-1-008 RUN DATE 04/10/96

ISSUE DATE

TOTAL

147.03
4 4

FD-60

GA WIC PROCEDURES MANUAL FY '97

Attachment FD-19

CUMULATIVE UNMATCHED REDEMPTIONS PART II EXAMPLE

PAGE REPORT EWRR351G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF MARCH

1996

CLINIC PAGE D/U/CL 01-1-008 RUN DATE 04/10/96

PART 2 NOT MATCHED TO VALID CERTIFICATION RECORD

VOUCHER REFERENCE ISSUE NUMBER NUMBER DATE

WIC ID

FEBRUARY JANUARY

FAMILY c p S AMOUNT S AMOUNT

RECONCILIATIONS

TOTAL

74620912 15692612 01/12/96 008007741 5 1 R 4.14

74620913 11454716 01/12/96 008007741 5 1

R 5.13

74620914 11454717 01/12/96 008007741 5 1

R 11.06

74620915 34537674 01/12/96 008007741 5 1

R 8.27

74621454 36190860 02/05/96 008008287 8 1 R 7.17

74621455 55336318 02/05/96 008008287 8 1 R 4.17

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

74621456 36163633 02/05/96 008008287 8 1 R 6.47

74621457 36163632 02/05/96 008008287 8 1 R 4.17

621502 60056231 01/02/96 008007096 4 2

R 9.00

/4621504 34792625 01/02/96 008007096 4 2

R 7.52

74621505 60056230 01/02/96 008007096 4 2

R 4.30

74621506 32816278 02/06/96 008007096 4 2 R 8.48

74621507 36598558 02/06/96 008007096 4 2 R 4.45

74621509 36332739 02/06/96 008007096 4 2 R 4.46

74621755 36698773 02/13/96 440134495 9 2 R 8.85

74621818 36698562 02/13/96 008008171 4 1 R 3.48

74621820 15835402 02/13/96 008008171 4 1 R 7.97

74621821 55637585 02/13/96 008008171 4 1 R 8.31

74621822 36593568 01/09/96 008006036 1 2 R 9.10

74621823 42729901 01/09/96 008006036 1 2

R 4.40

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

FD-61

GA WIC PROCEDURES MANUAL FY '97
LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

Attachment FD-20

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

DISTRICT/UNIT/CLINIC:

INSTRUCTIONS

-USE TinS FORM TO REPORT VOUCHERS (CO?vfPUTER OR MANUAL)

WinCH HAVE BEEN LOST, STOLEN, OR DESTROYED BY EITHER THE

PARTICIPANT OR THE CLINIC.

- SUBMIT AT LEAST MONTHLY.

-MAIL TO:

VIKING CO?vfPUTING, INC.

GEORGIA WIC UNIT

P.O. BOX 2504

GREENWOOD, IN 46142-2504

DATE: STATUS CODES
LOST/STOLEN/DESTROYED -2 VOIDED-3

BEGINNING VOUCHER NO.

ENDING VOUCHER NO.

QUANTITY

WIC !.D. NUMBER

STATUS CODE

COMMENTS

1191

I TOTAL VOUCHERS

11

FD-62

TABLE OF CONTENTS

I. Introduction

QI-1

II. Momtonng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . QI-1

III. Participant Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . QI-2

IV. Repayment ofWIC Funds Procedure.................................... QI-7 V. Guidelines for Investigating Employee Abuse............................. QI-8 VI. Procedures to Request an Employee Investigation .....,. . . . . . . . . . . . . . . . . . . . QI-8 VII. Vendor Compliance Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . QI-9 VIII. Compliance Investigation Food Purchases................................ QI-9 IX. Disqualified Vendor/Participant Hardship ................................ QI-10 X.

XI. Voucherlssuance Security ............................................ QI-12

Attachments: QI-1 Closeout Reconciliation Report ........................................ QI-15

GA WIC PROCEDURES MANUAL FY '97 QI-2 Quality ImprovemenLVoucher Investigation Log .......................... QI-16 QI-3 Participant Sample Warning Letter ..................................... QI-17 QI-4 ' Request forlnvestigation Form ........................................ QI-18 QI-5 WIC Transaction Report ............................................. QI-19 QI-6 Verification Form Disqualified Vendor
Hardship to WIC Participant .......................................... QI-20 QI-7 Georgia WIC Program Vendor Donation List ............................. QI-21 QI-8 Notification Summary of Missing VouchersNOC Cards .................... QI-22

GA WIC PROCEDURES MANUAL FY '97

I.

INTRODUCTION

The objective ofthe 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.

II.

MONITORING

1. 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-Self Reviews.

2. If the review of vouchers/voucher related materials causes suspicion, and the Coordinator determines that .~ investigation is needed, the Coordinator shall notify the State WIC Office. and proceed with the investigation. The State WIC Office shall notify USDA-FNS ofthe impending investigation and keep them informed ofcase progress on a periodic basis or as requested/necessary.

3. Vouchers marked VOID will be checked against the Reconciliation Report (see Attachment QI-1). This report is generated at the clinic level and gives the final disposition of all computer printed vouchers.

4. Investigations may include review ofthe voucher register, voucher inventory, cashed vouchers, certification records, ~!~pl()y~I:a,tiv~?particiJ??.:@g"!P..JP~ ~9fg{pgf~i and if necessary, contacting WIC participants to veritY 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.

QI -1

GA WIC PROCEDURES MANUAL FY '97

ID.

PARTICIPANT ABUSE

A. Dual Participation

Dual participation occurs when individuals receive benefits ll,in(e';lfia:tf:Pfi.ee in the same clinic, or from more than one clinic. The '"\vtc-'p;~gr:an;:
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 ~>Composite Dual Participation Report to the State WIC Office, ~qi[f each Local Agency. 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. Upon receipt ofthese completed reports, the State Agency will eliminate obvious false duplicates by:

I. 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!~ resolved.

The following are examples of possible dual participation situations and the procedures for reconciliation.

I. Participant Enrolled in the Same Local Agency at the Same Clinic Site.

Investigate to determine if there is any difference in the spelling of the first name. If so, twins may be enrolled. If the first names are spelled exactly the same, then investigate clinical records to determine if it is the same participant or two different participants. Document <;!:i!!l?.!H2ef!~g information obtained and the final action taken on each case lri the participant's health and issuance records.

The current TAD field code #52 allows the system to identify multiple births. This should reduce, if not eliminate, twins from appearing on the dual participation report.

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GA WIC PROCEDURES MANUAL FY '97

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. Ifnot, 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. If the participant has moved, the Local

Agency from which the participant moved must terminate the

participant. If dual participation and/or intentional fraud is involved

refer to the Section below (Participant Abuses and Sanctions) for

procedures regarding how to proceed with this type of abuse.

a part oftlie Documentation of (i~~j.paf11)'ij information and final action on

each case must become

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 Termination/Ineligibility/Waiting Form must be completed. The specific program abuse must be entered in the appropriate space. A copy of the form must be filed in the participant's health record.

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.

The maximum amount of time a participant may be suspended is three (3)

QI-3

GA WIC PROCEDURES MANUAL FY '97
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 only 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.
1. 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 of WIC regulations.
If the 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 of benefits" 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 distribution. 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:
QI-4

GA WIC PROCEDURES MANUAL FY '97



Copy of the front and back of the WIC

Assessment/Certification Form signed by the participant or

authorized representative.



The serial number of all WIC 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. If the misrepresentation or falsification is determined to be intentional, the State Agency will proceed as follows:



Secure the vouchers cashed by the participant fromcoJ!fuict

p~~ 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 aet~@~~-~.the participant f~ 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 fmdings 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 of their right to a fair hearing. '

c. Ifthe total value of benefits issued is less than $100, it will be documented in the participants health record. No recovery action will be initiated the first

QI-5

GA WIC PROCEDURES MANUAL FY '97
time, however, a. and b. above still apply. If the same 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, ofthe 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 ofvouchers 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 of his/her right to a fair hearing (see RO-Section-Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Abuse #2d) will be implemented.
4. ABUSE: Receiving cash for vouchers from food vendors, or credit toward purchase ofunauthorized food or other items ofvalue 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 of his/her right to a fair hearing (see RO-Section-Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (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.
QI-6

GA WIC PROCEDURES MANUAL FY '97

SANCTION: The participant should be warned, in writing, of the inappropriate verbal behavior and the action that will be taken if the 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.

IV.

REPAYMENT OF WIC FUNDS PROCEDURE

A. Repayments will be submitted to the local agency and must be in the form of a cashier's check or money order Payable to: DHRIWIC Program. Any other form of repayment is unacceptable (i.e. cash, personal checks, etc.).

1. The Local Agency will immediately forward all repayments received to the State Agency for processing.

2. If total payment is not made within the ninety (90) day timeframe, the Local Agency will notify the State agency which will in turn proceed with recovery actions prescribed under Georgia Statute.

B. Collection of claims for repayment of benefits is suspended if an appeal for a fair hearing is requested.

1. The suspension remains in effect until a fair hearing decision is rendered.

2. If a fair hearing decision at the local level is rendered in favor of the local agency, efforts to collect repayment must be resumed.

3. Repayment efforts must be resumed even if the local level decision is being appealed to the next level.

QI-7

GA WIC PROCEDURES MANUAL FY '97

V.

GillDELINES 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 assistance from the State WIC Office, and may require a Department of Human Resource Office of Fraud and Abuse (DHR-OFA) investigation.

(Intentional abuse is a deliberate effort to defraud the WIC program (example:
illegally taking WIC vouchers; giving false/misleading information in order to
become certified [qr 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 fmdings, 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 ofprosecution, shall notify the State WIC Office and the State WIC Office shall notify USDA-FNS.

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 REQUEST AN EMPLOYEE INVESTIGATION

1. The District Health Officer shall forward a letter requesting an investigation directly to the DHR-OFA and a copy of the 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 of Public 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.

QI-8

GA WIC PROCEDURES MANUAL FY '97

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 Coordinator, Program Manager, District Health Director and a copy to the State WIC Office.

VII.

VENDOR COMPLIANCE INVESTIGATION

Compliance investigations will be coordinated by the State WIC Office.

system' Investigations will occur at stores that have been identified as "f(ifn1ia1IY\High

Risk" by the State WIC Office through the use of the ADP.

~eports,

complaints, the Request for Investigation Forms received from the districts, ~Q

ft-.i;iF@.gqR1}~~1~s~!:~P:I9tgQ~I~~5~~n!fi~Per'pi~st~

A Request for Investigation Form (Attachment QI-4) should be completed on any store the local agency has reason to believe is violating WIC procedures. A copy of the Request for Investigation Form should be mailed as soon as possible to the
State WIC Office for action. J\..;.,.;.:::: : .. .f. S::.e::e:,:;;e.i,...X....I:M::'::::;:::;:T;: C:;.:o.;.;n.;.r.."laiilts,,X:;j"ig~C.a..i,'.n,.s..t:;:.'::,::;:::V:::ena:o:.].,;.:.':.s.~:';.;.:; :'. :i.::n.;.'...1..n...e;:;:V;';.;.;.;.l;.;.i; ,.a,....o.. 'r"
l?!9~'!~$1~~9!~~'QI-,,@~J,ffi!\H~~~,

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 must be documented by completing the WIC Transaction Report (Attachment QI-5). The original copy of this form must be
submitted to the State WIC Office. '. ,O,tJoli,.,.i,..n.5,.,t.,f.,,f.,i,.,c.,:;a.,.f,..i..;o.,.;:..,.f, .f..'..t..Yi~.:..f..u..e..,r..E..o..o..,.a,.l..f.l..f.J':et,n..c,....'."::'..l..l..i.e.i.,S..t,..a..t..e..

Vlll.

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 up for that purpose.
The Local Agency will not be notified when investigations are in progress in their area until after the investigations are completed.
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 ire as follows:
*City and County Fire Department *City and County Police Department
QI-9

GA WIC PROCEDURES MANUAL FY '97

*Retirement Hames

*Battered Women Shelters

*Church Organizations

~.Hometess::snerrers

.. ...

. .:.

. ....;:. :::~:.>.:

:::::::::::::::.~;;.;.:::::::

:~sHoe:aYwssctoarutts
*Girl Scouts

The compliance investigator completes a Food Donation List (see Attachment QI-7) and submits it to the non-profit organization for verification of foods to be donated. A representative ofthe 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.

DISQUALIFIED VENDORIPARTICIPANT HARDSHIP

If a 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 accumulates 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-Terminations/Disqualification.

To assess participant hardship in obtaining WIC food as the result of a vendor disqualification, the State must initiate the verification process. The State will complete a Verification Form (Attachment QI-6) 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 and 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.

I('ffi~1Wli~!~~!R,:~;iWl!9 vendor creates hardship for participants, the state p;l,~ .e;,,x,,,f,.,e,,,,i.,,i,.,d.,',,},,t,,t,,:@,c,,,~~W'%'t''~;;o::d::f;:o::f,;iJ't*~r'x~d''B''a'"t''i""O"":'r<i': within fif.te.en (15) working days from receipt of the
verification fo1lll. (8~'i[probation ~~9!9:Ji~i[[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.

QI-10

GA WIC PROCEDURES MANUAL FY '97
Vlb.lihventy-ifiy~-.(2~) or-fi1ore~~P?vou@~rs .or_ fit'~(5J or moreVOCQ~[s'1tfe
P!~~!#g~;tl1~'Notfi.i~~oBts~~~t~~~!Qg:Y9uc~!~iyop c~~.(*~4.~P!~#t
iliSii~i1ii11~JiJ~l~!Z~?!f~~~l~
4~~i~.~~f~+;~gn~ctyypi}~:.9.qqQ~tm~Jheif}!Pv.~!isa~qf4thisJndivi~ual.~~~Y.rP91:t g~giH'.qfj.11y~sti&~tiqn,;().Qt~;gg~H!iri.Ptpy~m~!ftlJ~~:

B,

VOUCHER . . . .

REGISTER .

- .

... :;.-~

.

Docilip.ent the seriaJ.numbt;:rs~or thevotichers .that ate 1osrntstoleri;'().tf'tli~

cotriptttervou~he~!~~t~1'.9Fma!!l1aivot1her}ttvei1t()tyi

... '

L

To reqtieSf'?Y1Jp"Y.()H:~rc9!es, ~fupl!e tlie:Ql!@IYJfilp~~~l!~i!!

V<Jgher;lj}~*-!!g~~9g~~ogJ#\tta.!nhepfQP~) ~~tl.t:tli ~9B9.w.w;~~

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b. CUttentdate

....>-'<.:-:---.'.

c.

Re~()~ f()~ !f;y~sti~~ti()n (is frapsijsp~pt~4<~tS".)

d. Lisrvouchetnumbers

e. ~~~~~ ~~~~: (4ii~jni~@.lg!f:#i~E~~Y.<>ftcJl~t)

f. Glipi?iiUiiiber
g~ s~4ti~ij!!~.~~b~~;'(~l:len~ppli~I~)

h: Sign a.tid~ate

QI-11

GA WIC PROCEDURES MANUAL FY '97 ~it~m1tm!ffig'1:9~:;~~P1~t.~P:~~P.!!~Y~t0WJY}Y99~~f!p(}p~~~~:fg~fP~~ t~<I~~s~4~
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. WICvouchers are negotiable items which are presented to the bank as a check for cash for reimbursement. Therefore all vouchers mu~t be securely protected as checks or cash in order to help prevent voucher theft, and deter program fraud.
1. All vouchers must be stored in a locked cabinet, desk, or closet, when not QI-12

GA WIC PROCEDURES MANUAL FY '97
being issued. The key which locks the cabinet, desk, or closet must be stored in a secure location, (change location ofkeys occasionally);
2. When issuing manual vouchers from a computer, the clerk must ~:itiB:H:t before leaving the work station;
3. When more than one person is using the same terminal, each person must log (:)'9:t upon completion oftheir printing job;
4. Pass words must be changed at a minimum, twice a year;
. ~~~..~Y2R.1;~r'lli~g::!~!PP19~T"~fs~i:~'gt~P.9:'1qP:s~-tT~~P:il?~$;t i~~~~YsP.~r\~I;m.~1f9!!9!m&'l?.ws~~~~t~li.9.m~.!i.Jw.P!~!#f4!~9~ P~!~~I~P!.9Y~~~m.r~'[1J!:!gip~f~~.~s2~:::Ef+;eypp;J~~~~Z?1
~i~~~,;~erg~~t!l~~~~P~,~x~~:.@~Y<Ja~xfin!fl~~~
to~
~~~i[~~fl~ii=~J.li~l~~~~?!f.~n~l?P:Ms~!?I~J.:
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. Voucher Security
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 ofthe reach of the participants, or there must be a physical barrier between the vouchers and the participant;
QI -13

GA WIC PROCEDURES MANUAL FY '97 C. VOUCHER STORAGE At a minimum, districts must meet one of the following voucher storage procedures when clinics are closed: 1. If vouchers are locked in a standard cabinet, the cabinet must be in a locked room, within a locked building; 2. A locked cabinet in a locked building with an alarm system; 3. A fire proof insulated security file cabinet with combination lock, securely attached to the floor, in a locked building; 4. A safe securely attached to the floor in a locked building; 5. Vault in a locked building. D. TRANSPORTING WIC VOUCHERS 1. 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)
QI-14

GA WIC PROCEDURES MANUAL FY '97 CLOSEOUT RECONCILIATION REPORT

Attachment QI-1

PAGE 20634

STATE OF GEORGIA WIC SYSTEM

REPORT EWRR840G

CLOSEOUT RECONCILIATION REPORT

GRADY MATL & INFANT CARE FOR THE CLOSEOUT MONTH OF JUNE 1995

VOUCHER NUMBER 25709399 26499328 26488329 26488330 26488331 25709404 25709405 25709406 25709407 25709412 25709413 25709414 25709415 25709420 25709421 25709422 25709423 26488336 26488337 26488338 26488339 16488344 ..!6488345 26488346 26488347 26488352 26488353 25709428 25709429 25709430 25709431 25488356 26488357 26488358 26488359 26488364 26488365 26488366 26488367 25709436 25709437 25709438 25709439 26488380 26488381 26488382

WICID
REFERENCE FAMILY c p

NUMBER

55236263

999054588 2

48629635

697012089 2

697012089 2

48629615

697012089 2

48629626

697012089 2

63771576

699126861 3

63771588

699126861 3

63771592

699126861 3

63771629

699126861 3

63771624

999043937 5

63771617

999043937 5 1

63771570

999043937 5

63771616

999043937 5

52185535

697010260

52185541

697010260

52185557

697010260

52185542

697010260 1 1

63851783

697008023 7

67212999

697008023 7

63851787

697008023 7

67213000

697008023 7

67212970

699148954 0

42701052

699148954 0

63778323

699148954 0

67212998

699148954 0

63851800

695100454 5

63851799

695100454 5 1

63867366

697004511 5 1

63867371

697004511 5 1

63867382

697004511 5 1

63857574

697004511 5 1

42501104

999051530 7 1

68637805

999051530 7 1

42502548

999051530 7 1

68637825

999051530 7 1

42501097

697009847 8

68637806

697009847 8

42502547

697009847 8 1

68637826

697009847 8 1

63827114

999047451 3 1

63827113

999047451 3

63771610

999047451 3

48827778

999047451 3

697005800 2

697005800 1 2

697005800 1 2

PARTICIPANT LAST
RARRIS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINGS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS HAWKINS

FIRST
MARQUIS ANTONIO ANTONIO ANTONIO ANTONIO ANTONIO ANTONIO ANTRINA ANTRINA
CHAZ CHAZ CHAZ CHAZ CHRISTOPHER CHRISTOPHER CHRISTOPHER CHRISTOPHER DEANGELO DEANGELO DEANGELO DEANGELO DEMETRIUS DEMETRIUS DEMETRIUS DEMETRIUS DERRICK DERRICK JAMAL JAMAL JAMAL JAMAL JEREMY JEREMY JEREMY JEREMY JESSICA JESSICA JESSICA JESSICA KIERRA KIERRA KIERRA KIERRA KIMBERLY KIMBERLY KIMBERLY

VCHR TYPE
055 047 039 025 039 028 031 037 054 047 039 025 039 047 039 025 039 031 037 039 055 028 031 037 054 068 072 031 037 039 055 031 037 039 055 031 037 039 055 031 037 039 055 028 031 054

CLINICPAGE 9 DIU/CL 12-0-999
RUN DATE 07/13/95

REDMO AMT
10.61 12.14 .00 9.82 6.33 8.20 8.92 14.54 12.26 12.14 6.33 9.82 6.33 12.22 6.13 10.37 6.13 8.92 13.71 6.33 9.10 7.18 7.23 14.54 8.37 58.87 51.40 8.92 14.54 6.33 9.91 8.92 14.54 6.33 9.91 8.92 14.54 6.33 9.91 6.87 6.95 6.33 8.58 .00 .00 .00

DATE ISSUED
04/06/95 04/14/95 04/14/95 04/14/95 04/14/95 04/06/95 04/06/95 04/05/95 04/06/95 04/06/95 04/06/95 04/06/95 04/06/95 04/12/95 04/12/95 04/12/95 04/12/95 04/11/95 04/11/95 04/11195 04/11/95 04/06/95 04/06/95 04/06/95 04/06/95 04/111.95 04/11195 04/11/95 04111/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/10/95 04/10/95 04/10/95 04/10/95 04/06/95 04/06/95 04/06/95 04/06/95 04/04/95 04/04/95 04/04/95

STATUS DATE
05/10/95 04/18/95
04/14/95 04/18/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/19/95 04/19/95 04/19/95 04/12/95 04/13/95 05/01/95 04/13/95 05/01195 05/01/95 05/26/95 04/10/95 05/01195 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 04/10/95 04/10/95 04/10/95 04/06/95 04/30/95 04/30/95 04/30/95

CMNTS EXP
04/18/95
VOID VOID VOID

TOTAL VOUCHERS CASHED TOTAL VOUCHERS EXPIRED TOTAL UNMATCHED TO CERT RECORDS TOTAL VOUCHERS ISSUED VOIDED
NCLAIMED TOTAL VOUCHERS CREATED

805 73 0 878 135
0 1,013

CLINIC TOTALS 11,199.66
.00 11,199.66 (TOTAL OF AND EXPIRED)
11,199.66 (COMPUTED AND MANUAL VOUCHERS)

QI-15

GA WIC PROCEDURES MANUAL FY '97
QUALITY IMPROVEMENT VOUCHER INVESTIGATION LOG

Attachment QI-2

DISTRICTfUNir: - - - - - - - - -

DATE: ______________

REASON FOR I N V E S T I G A T I O N : - - - - - - - - - - - - - - - - - - - - - -

VOUCHER ISSUE CLINIC

NUMBER DATE

#

COMPLETEDBY:____________________________________~DATE: __________________

Form 3789 (1-93)

Routing- White Copy- State WIC Office, Yellow - Local Agency

QI-16

GA WIC PROCEDURES MANUAL FY '97 PARTICIP,ANT 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/she can become healthy. The food must be given to him/her and not sold to anyone. If you continue to sell your WIC 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-17

GA WIC PROCEDURES MANUAL FY '97 REQUEST FOR INVESTIGATION FORM

Attachment QI-4

' Georgia Department of Human Resources WIC REQUEST FOR INVESTIGATION
2. NAME AND OffiCE OF OffiCIAL TO WHOM FORM SUB.MITTED
TO:
-
4. NAME AND ADDRESS OF STORE (INCLUDE STREET, CITY, STATE AND COUNTY)

'!.DAlE 3. NAME OF PERSON SUBMITIING FORM
(INCLUDE DISTRICT)
FROM:
5. TYPE OF STORE OR FIRM

6. VENDOR NUMBER

7. NAME OF OWNER OR MANAGER
"'
8. ETIINIC MAKEUP OF STORE'S CLIENTELE

- - - - 9. HAS STORE BEEN PREVIOUSLY INVESTIGATED? YES

NO

10. ARE THERE OTHER STORES UNDER THE SAME OWNERSHIP WHICH ARE AUTHORIZED FOR PARTICIPATION?

- - YES

NO

IfYes, fill in their names and address.

II. TYPES OF ABUSES FOR WHICH INVESTIGATION IS REQUESTED. 12. OTHER INFORMATION USEFUL TO THE INVESTIGATOR (PROVIDE ADDmONAL SHEETS IF NECESSARY)

Form 3775 (3-83)

ROUTING- White Copy- Stille WIC Offu:e, YeUow Copy- Local Agency
QI-18

GA WIC PROCEDURES MANUAL FY '97 ?WIC TRANSACTION REPORT

Attachment QI-5

VOUCHER NUMBER STORE NAME AND ADDRESS:

O.Orgia Department of Human Resources Division ofPublic Health WICProgram
WIC TRANSACTION REPORT (WTR)

VOUCHER NUMBER WTR RETURNED TO WIC AGENCY:

1.!, ----------~Representative ofWIC Program, Department ofHuman Resources, make the following statement freely and voluntarily, knowing that this statement

may be used in evidence.

2.0n (date)----.,..,...,....,,..---' at about (time)

I entered the subject store. I selected the items specificied below. At the check-out counter there (was/were)

- - - - - - Person(s) in line ahead of me and_ Person(s) in line behind me. The clerk sold to me the items listed below at a total cost of (if available) S

. I used the

WIC food instrument indicated above. The price of the item(s) was marked on the itern(s) or shall indicated below. During check-out, the voucher was in plain view of the clerk who served me.

For those items not priced marked, the price was verified by --:-:-=:---:----------=-:-::-------------------

3.Time Entered Stsore

Approached Checkout-------::-:- Left Store

4.CHECKLIST

Yes No

Yes No

Yes No

Prices Marked on Food(s) or Shelf

' Rang Up Sale

Adequate Supply ofWic

Recorded Price on Voucher

Identification Card

S.COMMENTS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Ch_eck_ ed _ _ _ _ _ _ _ _ _G_ ave_ Rec_ eipt_to I_ nve_ stiga_ tor_ _ _ _ _ _ _ _ _ _ __

- - - - - - - - - - - - - - - - - - - - - - - D E S C R I P T I O N OF CLERK (APPROXIMATE)

!.SEX

I 2.RACE

7. OTHER IDENTIFYING INFORMATION

I 3.AGE

I 4.HEIGHT

5. WEIGHT

_I 6. HAIR COLOR

8. IDENTIFIED DURING TRANSACTION AS (NAME) TITLE, RELATIONSHIP TO OWNER

IELIGIBLE ITEMS QUANTITY
IINELIGIBLE ITEMS QMNTITY

I SUMMARY OF PURCHASE

BRAND NAME

ITEM

9. MEANS OF IDENTIFICATION PRICE

ITEM

PRICE

ITEMS REFUSED QUANTITY

ITEM

NAME TITLE

' '
I DATE I REPRESENTATIVE SIGNATURE

Form 3773 (791)

ROUTING WHITE COPY Sf'ATE WIC OFFICE

YELLOW COPY- LOCAL AGENCY

QI-19

GA WIC PROCEDURES MANUAL FY '97

Attachment QI-6

VERIFICATION FORM DISQUALIFIED VENDOR HARDSHIP TO WIC PARTICIPANT

GEORGIA WIC PROGRAM VERIFICATION FORM
DISQUALIFIED VENDOR HARDSHIP TO WIC PARTICIPANT

To Be Completed by State WIC Office
District/Unit
Name of Disqualified Vendor Address

Vendor _ _ _ __

To Be Completed by Local Agency List WIC Vendors Located Near Disqualified Vendor: Vendor Name Address (Street!Hwy
Distance In miles (only)
Vendor Name Address(StreetfHwy)
Distance In miles (only)
Vendor Name Address (StreetfHwy)
Distance In miles (only)
Recommendations:

QI-20

GA WIC PROCEDURES MANUAL FY '97
GEORGIA WIC PROGRAM VENDOR DONATION

Attachment QI-7

GEORGIA WIC PROGRAM VENDOR DONATION LIST

GALLONS

CANS

QUANTITY

Mll..K
I CEREAL
CHERRIOS

I oz.

I QTY.

CHEX,CORN

CHEX,RlCE

CHEX, WHEAT

COUNTRY CORN FLAKES

CRlSPY CRITTERS

HARVEST INSTANT OATMEAL PLUS OAT BRAN

JIM DANDY QUICK GRlTS (IRON FORTIFIED)

KlX

MINUTE 3 BRAND INSTANT OATMEAL

NABISCO CREAM OF WHEAT- (REGULAR FLAVOR)

PRODUCTI9

QUAKER INSTANT GRlTS -(REGULAR FLAVOR)

QUAKER INSTANT OATMEAL -(REGULAR FLAVOR)

TOTAL, CORN

TOTAL, WHEAT

KELLOGGS CORN FLAKES

SPECIALK

HARVEST INSTANT OATMEAL PLUS BRAN

JIM DANDY QUICK GRlTS

NABISCO CREAM OF WHEAT

CONTRACTED FORMULA

CHEESE

oz QTY.

AMERICAN

CHEDDAR

COLBY

MONTEREY GACK

MOZZARELLA

INSTANT CEREAL BEECHNUT GERBER HEINZ

oz

QTY.

WICRepresentativc'----------------
D~-----------
3790 (,\'. 4-95)

II JUICES APPLE
I
GRAPE

I BRANDNAME

GRAPEFRUIT

ORANGE

PINEAPPLE

OTHER

FROZEN

CANQTY

1=~ I I BRANDNAME

PEANUT BUTTER

BRAND NAME

I I I

EGGS

I

I

TUNA

BRAND NAME

oz.

QUANTITY

I I

oz.

QUANTITY

I I

QUANTITY
I

oz.

QUANTITY

CARROT

BRAND NAME

oz.

QUANTITY

Organization Name Address City Organization Representative Date _ _ _ _ _ _ __

Telephone.. Zip Code

PLEASE USE INK

QI- 21

GA WIC PROCEDURES MANUAL FY '97

Attachment QI-8

Georgia Department ofHuman Resources WICProgram
NOTIFICATION SUMMARY OF MISSING VOUCHERSNOC CARDS
COMPLETE: When 25 or more WIC vouchers; S or more VOC cards; are missing. (A lost/stolen/voucher report must be completed for all missing vouchers) IMMEDIATELY: Notify Supervisor; WIC/Coordinator; and the Police.
Complete the following information: (ALL SECTIONS MUST BE COMPLETED) '

SECTION I Name of person who discovered the vouchers!VOC cards missing Name ofperson completing this form, if different from above SECTIOND Name ofperson(s), who is responsible for vouchers!VOC cards at this clinic.

D/U/C

SECTION ill

Number of Missing Voucher(s)

Number ofMissing VOC Cards

NOTE: A separate form must be completed if both Vouchers and VOC cards are missing

Discovered missing: Date

Time

Supervisor notified: Date

Time

Coordinator notified: Date

Time

VOUCHER'S Beginning#

Ending#

VOC CARDS Beginning #

Ending#

am_ _ _ pm_ _ _ am_ _ _ pm_ _ _ am_ _ _ pm_ _ _

SECTION IV Complete a detailed summary of how vouchers!VOC cards were discovered missing.

SECTIONV List any additional information that would apply to this case.

Use additional sheets ofpaper if needed, and attach)

(Use additional sheets of paper ifneeded, and attach)

SECTION VI

Signature ofperson completing report

(Submit completed report to WIC Coordinator/Person in charge)

Person receiving the report

Title

(This signature is to verify receipt ofthis report, not to verify information on report)

WIC Coordinator or designee, shall submit a copy ofthis report to the State WIC Office within three (3) working days.

Koutmg: w mte copy-:swu

l'lllK l-0PY-UIStnCt

Date
Yellow copy-Clime

Form (2-96)

r~.ti~~:'!VJ!!'.l$,'if!~~.9.%'11~~~r~:~!:'~l~~~~Yr.~.J.J!;;~!ll'.ll:11!!~~!~~ttum~~titi?-~~$!!~~ltf!!t.~~
!!!tffia'ntt~'i'~liilfiVliluttlitttl~r;~;t~ii~~~l)l:CJ!~~J!i~r&#!A&enm~~1@ml!~ot:~t!!!g:!!evaii!;,!!~!!iA~
ro~~i

QI-22

TABLE OF CONTENTS
I. State Agency Monitoring ............................................. MO-l A. Introduction .................................................... MO-l B. Monitoring Schedule ............................................. MO-l C. Clinic & Health Record Selection ................................... M0-2 D. Pre-Review Activities ............................................ M0-3 E. Files .......................................................... M0-3 F. TimefraiD.es .................................................... M0-5 G. On-Site Visit ................................................... M0-6 1. Entrance Conference .......................................... M0-6 2. Exit Conference .............................................. M0-6 H. Written Reports ................................................. M0-6 I. Close-Out Report ................................................ M0-8
II. Quality Assurance Self-Reviews ....................................... M0-8
B3
III. Technical Assistance ................................................ M0-9
Attachments: MO-l Local Agency Monitoring Tool ....................................... M0-10

GA WIC PROCEDURES MANUAL FY'97

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 of reviewing local agency operation. The districts/agencies which are not monitored for the year will receive priority for on-site technical assistance. The purpose of~\ffi(:).ffi.Jpt@lg visit is to ensure local agency compliance with State and Federal WIC.;egulati'b'D:;:"' The review will consist of an evaluation of program administration, voucher issuance, certification, food package assignment, nutrition education and of.e':a:<s>t:Af;..:':e::e:o:.f::f:ix::~.J~.~
In order for the above areas to be thoroughly evaluated, it is necessary for the monitoring team to observe at least one (1) clinic in full operation. A minimum of three (3) certifications/subsequent certifications must be observed. If the 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 ofNutrition. Every effort will be made to conduct all portions (Programmatic, Financial, Vendor, Quality Improvement, Systems, Nutrition ~g;~;~~~~affig) of the 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 ofNutrition, 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 St,#~Lw:!SJ.i(g>Jl,i.~ two (2) months prior to their scheduled review. The WIC Coordlnato~Wiifbe 'notified by phone, approximately one (1) month prior to the review, of the specific clinics (randomly selected and staffselected) 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'97
C. Clinic and Health Record Selection
1. Clinic Site
Every two (2) years, twenty percent (20%) ofthe total number of clinics in the state are randomly selected for program monitoring evaluation. The follo-wing 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~fti~Jt~~l!i.BA 2&!h~;;!!.I~{.1P:!g
b. Each local agency may have a maximum offive (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. If a 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 follo-wing 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
M0-2

GA WIC PROCEDURES MANUAL FY'97
clinic.
b. Fifty percent (50%) of the 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.
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 I''l''e'"''i''2'J:Hf;'_",_'-:.a.,.o,.,,.o,.,.,v.,_e,.,.J,,
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 t"f5.;:ii, aoove:
'.~;.;.;..;: -:-:.;.;.;.::..
c. If a 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 staff will 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:
M0-3

GA WIC PROCEDURES MANUAL FY'97

1.

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

11.

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

2 $ ' ;.-;.:::..:~:;..~.

:B-:.f::e:V.a:O:s:-;r,::..:;.t~;_e~.:e,:;:fv~f:::i:~~h:;'~~;:d..~i~-:i-~a-:-f::f;.:i..\.:..;,o;.,f-.;u:::+'::M;;:a~::;t.:e:;:r:-;:i~~a';;J<N<~.S.::

29.

Lesson Plans

30.

Training Files

30. Financial Management Files:

General Ledger (current and previous year)

General Journal (current and previous year)

M0-4

GA WIC PROCEDURES MANUAL FY'97

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

F. Timeframes

The program review process will be conducted within the following timeframes:

ACTIVITY 1. Notifications of intent to conduct a review-
SWO/OON. contact Local Agency to discuss possible review dates.

TIME FRAME 30 days prior to the scheduled date.

2. SWO/OON prepares and submits a report of program observation and review to Local Agency.

within 30 days ofthe exit interviews

3. Local Agency submits response to program review to SWO/OON.

within 45 days of the date of program review report

4. SWO/OON submits written response to the
Local Agency review.

within 15 days of the 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.

within 140 days of the exit interview. ,

M0-5

GA WIC PROCEDURES MANUAL FY'97
G. On-Site Visit
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 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 staff will:
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 wiij 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
M0-6

GA WIC PROCEDURES MANUAL FY'97
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 How? are addressed. For example: who will be trained, what will the training be on, when will they be trained, where will the training be held, and how will the training be conducted.
NOTE: All training must 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 oftraining and a list of staffthat 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 monitoring 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 ofprocedures 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 staffindicating 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:
1. 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 of the exit conference.
M0-7

GA WIC PROCEDURES MANUAL FY'97
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 ofthe action plan.
I. Close-Out Report
A written close-out report will be sent to the Local Agency upon the satisfactory resolution of all corrective actions. The close-out report is written documentation that the corrective action plan has been accepted and the program review is closed. All program reviews must be closed within 140 days of the exit interview.
II. QUALITY ASSURANCE SELF-REVIEWS
A. 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 ofnon-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.
B. Self Reviews
The Local Agency must conduct an internal self-review annually. The assessment will include all phases of the 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
M0-8

GA WIC PROCEDURES MANUAL FY'97
Outreach and Referrals Processing Standards Certification Procedures Chart Audit Accountability of Food Instrument and Issuance Materials Nutrition Services Breastfeeding Promotion and Support Services Financial Records & Expenditures Civil Rights Compliance Participant Complaints Fair Hearing Review Records of Employees on the WIC Program Review CertificationNoucher Issuance Records for Employee's Relatives
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.
ill. 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 local 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 lo~al agencies will be documented on a Technical Assistance Report form. A copy of this report will be placed in the District's file and a copy will be sent to the-District WIC Coordinator.
M0-9

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l

STATE OF GEORGIA Department of Human Resources
Division ofPublic Health State WIC Office Office of Nutrition
LOCAL AGENCY MONITORING TOOL
FFY'97

M0-10

GA WIC PROCEDURES MANUAL FY'97

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

Certification/Nutrition Education (Office of Nutrition)

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

1

LOCAL AGENCY MONITORING PART I AD:MINISTRATION 1. Name of District/Local Agency:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Add' ress:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

WIC Coordinator:_______Telephone #_ _ _ _ _ _ _ _ _ _ _ __

2. Clinic(s) to be Reviewed: (Attach a copy of the District Clinic Listing)

1. Clinic#

Clinic Name

2. Clinic#

Clinic Name

3.
Clinic#

Clinic Name

4. Clinic#

Clinic Name

5.
Clinic#

Clinic Name

3. Review Schedule

Entrance Conference:

Date:

Time:

Exit Conference:

Place:

Date:

Time:

Place:

2

GA WIC PROCEDURES MANUAL FY'97

PART I ADMINISTRATIVE SECTION

Guidelines

Areas of Review

Recommendation

I. Program Management (District Office)

A. Is an organizational chart available for review? (Attach a copy)

Attachment MO-l (cont'd)

Yes No NA

Comments

Corrective Action Corrective Action Recommendation
Corrective Action Corrective Action Corrective Action Corrective Action
Recommendation

B. Policy and Procedures 1. Does the District Office have a copy of all Policy Memorandums on file?
2. Is a copy of the Procedures Manual located at
the District Office?
c. System Maintenance Indicators
1. Are System Maintenance Indicators in compliance with State Standards? (Review these reports prior to an on site monitoring/selfreview visit(s). In the event a District/local agencies non-participation rate is 10% or above a technical assistance and/or a plan must be submitted to the State WIC Office.
2. Is at least 55% of prenatal caseload enrolled in
the first trimester?
D. Caseload Management (must have approval from state) 1. Has the District implemented a waiting list since the last review?
2. Is there a current waiting list? Ifyes, what
Priorities are being served?
E. Internal Communication
1. Are new policies and State Memos sent to staff?
Are staff meetings held regularly?
Date ofthe last meeting:
2. Is there a planned method of communication
between WIC staff and non-WIC staff? (i.e. Staff Meetings)

3

GA WIC PROCEDURES MANUAL FY'97

Guidelines Recommendation
'
Corrective Action
Corrective Action

Areas of Review

Yes

3. Is in-service training conducted regularly for WIC and non-WIC staff providing WIC services?

Date ofthe last meeting:
F. Fair Hearings/Participant Complaints (Review District files prior to monitoring Review)

1. 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:

Attachment MO-l (cont'd)

No NA

Comments

Corrective Action
Recommendation Corrective Action

G. Quality Assurance Self Review
1. Does the District conduct internal monitoring? (Review the Monitoring File) (Attach a copy ofthe Review Schedule)
2. Is there a list of deficiencies identified for each clinic?
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?

4

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines Recommendation
Corrective Action Corrective Action Recommendation

Areas of Review

Yes

H. Outreach

1. 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?
If no, 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?

No NA

Comments

Corrective Action

4. Are high risk participants contacted prior to termination.
If yes, please describe how the contact is made?
If no, please explain. (Review documentation)

5

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action
'

Areas of Review

Yes No NA

5. Have special provisions been made for
scheduling the following applicants? Explain:

Employed Participants

Clinic

Commem.,.

Clinic

Rural Participants

Clinic

Migrants

-

Corrective Action

6. Are grass roots organizations, .minority group and other

agencies serving potentially eligible WIC clients

informed ofWIC eligibility requirements and

significant program changes?

Corrective Action Corrective Action

If yes, is a listing ofthese groups and organizations on file in the clinic? (Review documentation)
I. Referral Section 1. Are WIC outreach materials sent to the 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?

6

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines Corrective Action

Areas of Review

Yes

No NA

K. Civil Rights Training
1. Is Civil Rights training conducted annually for local WIC staff? (District)

When

By Whom

Comments

Corrective Action I Corrective Action I
Corrective Action
Corrective Action Corrective Action
Corrective Action
I
I Corrective Action

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 of Complaints)
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 I. Has the general public been notified ofWIC Program information with regards to non-discrimination policy within the last 12 months? (District)
If yes, is there documentation ofhow it was done?
If no, please explain:
II. Clinic Review A. Caseload Management
I. 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.

7

GA WIC PROCEDURES MANUAL FY'97

Guidelines Recommendation
'
Recommendation

Areas of Review

Yes

B. Coordination and Integration

I. Are WIC services coordinated or integrated with other health depart:rrlent services?
2. Are WIC appointments coordinated:

Clinic

Attachment MO-l (cont'd)

No NA

-
Commen.

I Recommendation
Recommendation

3. How is this coordinated? 4. Are WIC participant medical records integrated with
other records?
Clinic

Recommendation Recommendation

5. If kept separate, why?

Clinic

Reason

--

--

--

--

--
6. Does clinic staff request or check immunization
records when WIC services are provided?
Clinic

.----
8

GA WIC PROCEDURES MANUAL FY'97

Guidelines Recommendation

Areas of Review
7. Does clinic flow appear to be smooth?
Clinic

Attachment MO-l (cont'd)

Yes

No NA

Comments

Recommendation

c. Complaints
1. Has the local agency received any complaints since the last review? (Review Staff local agency files).
Clinic

Recommendation

2. Review State/Local Agency Files. How many?
Clinic

Recommendation

3. Were the complaints resolved? Clinic

Corrective Action

D. Referrals 1. 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?

'

9

GA WIC PROCEDURES MANUAL FY'97

Guidelines
'

Areas of Review If yes, review documentation Clinic

Attachment MO-l (cont'd).

Yes

No NA

Comments

Recommendation

3. If no, what method is used to refer applkants/participants to other needed services?
Clinic

Recommendation

E. Processing Standards I. Does the local agency utilize an appointment system for scheduling applicants/participants appointments?
Clinic

Recommendation

2. Are no-shows and cancellations taken in account when
scheduling WIC appointments and other clinic activities? Clinic

Recommendation

3. If no, how are clients scheduled for WIC services? Clinic

10

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective 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

Corrective Action

5. What is the next available appointment for an applicant
requesting WIC benefits? (See appointment book)

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)

11

GA WIC PROCEDURES MANUAL FY'97

Guidelines
Corrective Action
'

Areas of Review
6. What are the processing standards time frames for:
(Ask Staff) Time Frames
Clinic(!)
Prenatal Postpartum Infants Children Migrants
Clinic(2)
Prenatal Postpartum Infants Children Migrants
Clinic(3)
Prenatal Postpartum Infants Children Migrants
Clinic(4)
Prenatal Postpartum Infants Children Migrants
Clinic(5)
Prenatal Postpartum Infants Children Migrants

Corrective Action

7. Is the clinic meeting processing standards? (See
documentation) Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

---

12

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action

Areas of Review

Yes No NA

F. Income Assessment
I. Is income taken before the certification process or after the certification?

Clinic

Comments

Corrective Action

2. What is the definition 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?
Clinic

Corrective Action

4. Are there certain situations when an applicanfs income must be verified?
Clinic

If yes, what are the situations? Clinic

13

GA WIC PROCEDURES MANUAL FY'97

Guidelines Corrective Action
'

Areas of Review
G. Certification Process
I. Are there instances when you must verify an applicant/participant's identification? Clinic

Attachment MO-l (cont'<!)_

Yes

No NA

Comments

Ifyes, please explain. Clinic

Corrective Action

2. What forms of participant identification do you accept?
Clinic

Corrective Action

3. Is the local staffknowledgeable of proper proced~es for notifying applicants and participants of their eligibility or ineligibility? (Staff interview and review Ineligible file) (Use Attachment I)
Clinic

Corrective Action

4. Are participants notified that their WIC certification is
about to expire prior to expiration of their certification period?
Clinic

14

GA WIC PROCEDURES MANUAL FY'97

Guidelines
I Corrective Action
I

Areas of Review 5. How are they notified and is the notification
documented?
Clinic

Attachment MO-l (cont'd)

Yes

No NA

Comments

Corrective Action

6. Are persons who are terminated during a valid
certification period notified prior to termination?
Clinic

Corrective Action

7. Certification Periods

Is the staff knowledgeable of certification periods? (Staff interviews)

Time Frames

Time Periods

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)

15

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines Corrective Action
'
Corrective Action

Areas of Review

Yes

8. Does the clinic provide WIC benefit only during a valid certification period?

(Select a sample ofrecords with the message "RECERT OVERDUE MMDDYY" to whom vouchers were issued to review compliance, use Attachment 2.)
9. Does the clinic allow a proxy to bring a child in for
recertification or to pick up vouchers?

Clinic

No NA

Comments

If yes, describe the circumstances. Clinic

Corrective Action

10. Does the local clinic have a system for transfers? (Complete Transfer of Certification Work Sheet Attachment 3)
Clinic

Corrective Action

II. Are VOC cards issued and accepted by the local clinic to verify WIC certification?
Clinic

16

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines Corrective Action

Areas of Review

Yes

No NA

12. Are the VOC card records accurate and monitored according to program policy? (Complete VOC Monitoring Work Sheet) Attachments 4 A and B

Clinic

Comments

Corrective Action

13. Are VOC cards stored in a locked place separate from the inventory log?
Clinic

Corrective Action

14. Is the inventory ofVOC cards conducted monthly ac.cording to program procedures? (Review physical inventory ofVOC Card Log)
Clinic

Corrective Action

15. Are two signatures of Local Agency Staff on VOC Card Inventory monthly?
Clinic

17

GA WIC PROCEDURES MANUAL FY'97

Attaclunent MO-l (cont'd)

Guidelines Corrective Action
'

Areas of Review

Yes

H. Special Population (Migrant)
1. Does the local agency caseload include migrants?

2. Is the staff knowledgeable of procedures for handling
migrants?

Clinic

Income VOC Cards

Clinic

Income VOC Cards

Clinic

Income VOC Cards

Clinic

Income VOC Cards

Clinic

Income VOC Cards

No NA

Comments

Corrective Action

I. Voter Registration 1. Is each participant issued a Voter Registration Form?
Clinic

Corrective Action

J. Smoking 1. Are No Smoking signs posted conspicuously located?
Clinic

18

GA WIC PROCEDURES MANUAL FY'97

Guidelines

If no, why not:

Areas of Review

Attachment MO-l (cont'd)

Yes

No NA

Comments

Corrective Action

K. Policy Memos/Procedures Manuals
1. Are all Procedures Manuals on file?
Clinic

Corrective Action

2. Is there a Procedures Manual located in the clinic? Clinic

Corrective Action

PART II. CIVIL RIGHTS
A. Administration 1. Are WIC services provided in non-discriminatory manner? Ask each clinic what they do!
Clinic

Corrective Action

2. Are facilities where WIC services are provided accessible to physically impaired persons without hardship? (Observation)
Clinic

'

19

GA WIC PROCEDURES MANUAL FY'97

Guidelines
Corrective Action
'

Areas of Review
3. Do facilities which are not accessible to physically impaired persons have written procedures for alternative arrangements to provide WIC services? (Review documentation)
Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

Corrective Action

4. Does the clinic serve non-English speaking applicants/participants?
Clinic

Corrective Action

5. Are interpreters or bilingual staff available for the nonEnglish speaking clients, if applicable?
Clinic

If no, explain how WIC information is communicated to them.
Clinic

Corrective Action

4. 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

GA WIC PROCEDURES MANUAL FY'97

Guidelines
Corrective Action

Areas of Review
C. Complaint Handling 1. Is staffknowledgeable of proper procedures for handling Civil Rights complaints?
Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

Corrective Action

2. Are participants informed of Civil Rights complaint
procedures? Clinic

Corrective Action

E. Compliance
1. Do all persons have equal opportunity in the WIC Program regardless ofrace color, national origin, age , sex, or handicap?
Clinic

Corrective Action

2. Does Local Agency comply with program policy of
determining participants racial/ethnicity?
Clinic

Corrective Action

ISSUANCE MATERIALS 1. Are vouchers mailed? Clinic

'

21

GA WIC PROCEDURES MANUAL FY'97

Guidelines
'
Corrective Action

Areas of Review
2. If yes, what procedures are used to mail vouchers. 3. Why are vouchers mailed? 4. Are the following items stored in a secure location:
1. Program Stamp 2. VOC Cards
Clinic

Attachment MO-l (cont'd)

Yes No NA

Comments

Corrective Action Corrective Action Corrective Action

v. RECORD REVIEW
(See Attachment 5) Copy additional sheets VI. CLINIC OBSERVATION
(See Attachment 6) VII. EQUIPMENT INVENTORY
(See Attachment 7)

22

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 1

INELIGIBLE CERTIFICATION WORK SHEET
Review three (3) records in each clinic of individuals found ineligible at the time of certification and/or ofindividuals who were terminated from the Program within the last year. Note: This information may be retainedfrom your ineligiblefile.
District._ _ _ _ _ _ _ _ _ _ _ _ _ __

Clinic

Name

Reason for Ineligibility or Termination

Was Notice of Fair Hearing
Given?

Signature & Date of Person Determining Eligibility Complete?

I I

I
I I
I
I

23

GA WIC PROCEDURES MANUAL FY'97 RECERT OVERDUE

ATTACHMENT 2

Select a random sample of at least three (3) records for which the following message "RECERT OVDUE MMDDYY' appears and to whom vouchers were issued. It is important that six-week postpartum women be in the sample. NOTE: This.. information should be taken offthe current voucher register.

District - - - - - - - - - - - - Clinic# - - - - -

.. Participant
Name

Month of Report

Status WIC

Delivery Date

Issue Date

Pick Up Date

RecertDue Date

Were Vouchers Validly Issued?

24

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 3

TRANSFER OF CERTIFICATION WORK SHEET

What is the District policy for accepting transfers?
Clinic Name: 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

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 4-A

VOC Card Numbers

DISTRICT ISSUED VOC CARDS
VOC Card Numbers

(Beginning #) '
Issue Date:

(Ending#)

(Beginning#) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning#) Issue Date:

(Ending#)

District/Clinic Name

Clinic Name

Yes

# Of Cards Issued No

Date Cards Issued

I

I

l

I
I

# ofVOC Cards on Hand

! !

I
I I
I
i I
i
Do these #'s match at Dzstrict and Clim.e? yes {} no {}
Is Inventory accurate? yes {} no {} Are there two (2) signatures? yes { } no { }

26

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 4-B

VOC Card Numbers

CLINIC ISSUED VrO-C--C--A-R--D-S---------------------------------, I VOC Card Numbers

(Beginning #) Issue Date:

(Ending#)

(Beginning#) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning #)

(Ending#)

Issue Date: - - - -

District/Clinic Name

# Of Cards Issued

Date Cards Issued
I

I
I

Clinic Name

Yes

No

# ofVOC Cards on Hand

I
I
I I
Do these #'s match at District and Clinic? yes {} no {} Is Inventory accurate? yes {} no {} Are there two (2) signatures? yes { } no { }

27

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 4-C

VOC CARD SECURITY REPORT

Pull five (5} records in each clinic from the VOC Card Log.

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_ Yes_ No_ Yes_ No_
- Yes No_
Yes_ No_

Signatures Match

Yes_ No_

i

Yes_ No_

i
i

Yes_ No_

I

Yes_ No_

I
I

- Yes No-

I

Yes_ No_

I

i

Yes_ No_

I

I

Yes_ No_

I

Yes_ No_

I

Yes_ No_

I

Yes_ No_

! i

Yes- No-

i

Yes_ No_

I

Yes_ No_

I

Yes_ No_

I

I

Yes_ No_

I

Yes_ No_

I

Yes_ No_

I

Yes- No-

!

Yes_ No_

I

I

Yes_ No_

I
i

I

Yes_ No_

I

Yes_ No_

i

Yes_ No_

Yes_ No_

- Yes No-
Yes_ No_

28

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 5

RECORD REVIEW

Review the following criteria in the records randomly selected by the Office of Nutrition:

PARTICIPANT NAME,_ _ _ _ _ _ _ _ _ _ __

C L I N I C_ _ _ _ _ _ _ _ _ _ _ __

CRITERIA TO REVIEW:
Initial Contact Date
Categorically Eligible?
Signature!fitle of Person Collecting Income/Residence Data
Participant's Signature/Date
Medicaid Eligibility Documented
Medicaid Number
Food Stamps YIN?
Number in Family?
Income Information Documented
Income Eligible?

Note: Make copies of this form for Record Review..

29

GA WIC PROCEDURES MANUAL FY'97 CLINIC OBSERVATION

ENVIRONMENT
'
1. Handicap Ramp

Clinic

Yes No

-----
--

2. "And Justice For All Poster"

Clinic

Yes No

----
--
--

ATTACHMENT 6

3. Is clinic flow efficient?

Clinic

Yes No

--
--
--
--
--

4. Were clinic participants waiting for long periods of time?

Clinic

Yes No

------

5. Does the clinic have comfortable waiting areas offering privacy for health screening and counseling?

Clinic

Yes No

--
--
---

6. Does the reviewer observe any prac that could be considered discrimina

Clinic

Yes No

--
--
----

7. Are participants treated with courtesy?

Clinic

Yes No

------

8. Is the VOC Card Poster displayed in the clinic?

Clinic

Yes No
--
-----

B. CERTIFICATION {INCOME)

1. Is income determined prior to nutritional risk assessment?

Clinic

Yes No

--
--
--
--
. ~

30

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 6 (CONT'D)

a. Medicaid/Food Stamp Verification

Clinic

Yes No

------

b. Are these accepted as income eligibility?

Clinic

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 a certification?

Clinic

Yes No

-----

3. Were participants informed of the following:

a. Rights and Obligations

Clinic

Yes No

--
---
--

b. VOC Card accepted/issued?

Clinic

Yes No

------

c. Was how to use I.D. Card explaine

Clinic

Yes No

------
'

31

GA WIC PROCEDURES MANUAL FY'97

ATTACHMENT 7

EOUWMENT~NTORY

Was the equipment inventory sent in by October 1 of the new fiscal year?

Can all the equipment be located?

Yes - - - No _ __

Clinic (Write in name)

Equipment Number

Located 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_ _

Comment

32

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

~T III FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA

Corrective Action

A. Packing List

l Comments

Corrective Action

Is a copy of the packing list received by the District within two days of clinic verification?
B. Voucher Issuance

1. Does the Local Agency have a policy for issuing vouchers to eligible WIC employees and their family members?

Corrective Action

2. Are any local agency staff receiving WIC benefits at

the clinic site where they work?

I

Corrective Action

3. Are any family members ofWIC staff receiving
benefits at local clinic where the staff is employed?

Corrective Action Corrective Action

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 ofparticipant's abuse since the last Program Review?

2. Was the report investigated?

I

3. Was the report sent to the State WIC Office?

Corrective Action

D. Dual Participation

1. Have there been any cases of intentional dual participation since the last monitoring review?

2. Was the report sent to the State WIC Office?

I

Corrective Action

E. Missing Vouchers

1. 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?

I
I
I
'

33

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action
'
Corrective Action
-
Corrective Action
Corrective Action
Corrective Action

Areas of Review

Yes No NA

III. Food Instrument Accountability (Clinical Review)

A. Manual Voucher Inventory Log

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. Perpetual Inventory

1. Is perpetual inventory done on all manual vouchers?(Weekly)

Clinic Clinic Clinic Clinic Clinic
2. Is perpetual inventory complete and
accurate?(Weekly)

Clinic Clinic Clinic Clinic Clinic
3. Is inventory done weekly?

Clinic Clinic Clinic Clinic Clinic

Comments I I I I

34

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

.___,.uidelines
Corrective Action
Corrective Action Corrective Action Corrective Action Corrective Action

Areas of Review
c. Manual Voucher Physical Inventory

Yes No NA

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

1. Are vouchers filed by serial number order?

Clinic Clinic Clinic Clinic Clinic

Comments
I

35

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines Corrective Action
'
Corrective Action Corrective Action
Corrective Action
Corrective Action
Corrective Action

Areas of Review

Yes

2. Are any vouchers missing or misfiled?

Clinic Clinic Clinic Clinic Clinic
3. Are vouchers kept in binder or folder?

Clinic Clinic Clinic Clinic Clinic
4. Have any vouchers been altered with write overs 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 ofpacking list sent to the District Office?

Clinic Clinic Clinic Clinic Clinic

No NA

Comments

i

-

36

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

f~uidelines Corrective Action
Corrective Action
Corrective Action
'
Corrective Action
Corrective Action

Areas of Review F. Voucher Register Documentation

Yes No NA

I. 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 Clinic Clinic Clinic
4. Are any participant's signatures missing?

Clinic Clinic Clinic Clinic Clinic
5. Does the Voucher Register contain required closeout
signatures and dates?

Clinic Clinic Clinic Clinic Clinic

Comments

I
I

37

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action
'
Corrective Action
Corrective Action
Corrective Action
Corrective Action

Areas of Review G. Voucher Security

Yes No NA

I. During office hours, are vouchers securely stored or in possession of authorized staff?
Clinic Clinic Clinic Clinic Clinic
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

Comments i

38

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

- .~uidelines Corrective Action
I
Corrective Action
Corrective Action Corrective Action

Areas of Review

Yes No NA

6. Are WIC ID cards stored separate from the Program
Stamp?

Clinic Clinic Clinic Clinic Clinic
7. What security measures are taken when an employee resigns or is no longer authorized to issue voucher(s)?
8. Are vouchers secured in a locked cabinet, closet or
safe when not being issued?
9. Is the key properly secured with only authorized
personnel?
H. Voucher Issuance

1. Does the Voucher Register show documentation of prorating vouchers?

Clinic Clinic Clinic Clinic Clinic
2. Is prorating consistent?

Clinic Clinic Clinic Clinic Clinic
3. Are unissued prorated vouchers stamped void at the
time of issuance?

Clinic Clinic Clinic Clinic Clinic

Comments I

39

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

I I

Guidelines

Corrective Action

Areas of Review

Yes No NA

4. Is staff knowledgeable ofthe proper procedures for prorating?

I Comments

'
Corrective Action

Clinic Clinic Clinic Clinic Clinic
5. Are voided vouchers stored according to procedures
until forwarded to the ADP contractor?

Corrective Action

Clinic Clinic Clinic Clinic Clinic
6. Are vouchers transported from one site to another?

Corrective Action

Clinic Clinic Clinic Clinic Clinic
7. When vouchers are transported, are they in a locked
container (lockbox, briefcase)?

Corrective Action

Clinic Clinic Clinic Clinic Clinic
I. Local Agency Policies

1. Does the local agency have a policy for issuing vouchers to employees/family members?

Corrective Action

Clinic Clinic Clinic Clinic Clinic
2. Are any staff in this clinic receiving WIC benefits at
this location?

Clinic

Clinic

Clinic

Clinic Clinic

-~

40

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

~~uidelines Corrective Action Corrective Action Corrective Action Corrective Action
Corrective Action

Areas of Review
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
5. Is the District aware of all staffi'family members
enrolled on the WIC Program?
Clinic Clinic Clinic Clinic Clinic
J. Participant Abuse
1. Has the clinic had any problems with participant's abuse since the last program review?
Clinic Clinic Clinic Clinic Clinic
2. Was the coordinator notified?
Clinic Clinic Clinic Clinic Clinic

Yes

No NA

Comments

I
I

41

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action
'
Recommendation
Recommendation
Corrective Action
Corrective Action

Areas of Review
3. To your knowledge was there an investigation
conducted?

Yes No NA

Clinic Clinic Clinic Clinic Clinic
D. Dual Participation

1. Has the clinic followed up on each dual participation case received at the clinic?

Clinic Clinic Clinic Clinic Clinic
2. Have there been any cases of intentional dual
participation since the last monitoring visit?

Clinic Clinic Clinic Clinic Clinic
K. Missing Vouchers

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

Comments I I

42

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

. ~uidelines
Corrective Action

Areas of Review

Yes No NA

3. Was supervisor/coordinator notified of the missing
vouchers?

Clinic Clinic Clinic Clinic Clinic

PART IV SYSTEMS INFORMATION UNIT

Guidelines

Areas of Review

I. General Information

Reviewer:

Date:

Yes No NA

Comments I
Comments

1. District/Unit:

2. Clinic Number:

I

3. Clinic Name/Address:

4. Contact Person: 5. Telephone: ( ) 6. GIST: II. District Information

1. Type of Systems Used:

ATVS

MVS

M&M

'
DIU System

I

2. Number of Computers Used for WIC

I

43

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
'

Areas of Review
3. Number of Clinic Staff authorized to use the
System:
4. Number of Clinic Staff listed as Supervisors:

Yes No NA

Comments

5. Request a list of authorized users for each ofthe
computers to be inspected.
6. Are any non-clinic 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 ofthe 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 re-position 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?

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?

44

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

........ uidelines

Areas of Review

Yes No NA

4. If voucher 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 of users and their passwords kept in the clinic?
7. Do users routinely log out of the system each time
they are done writing TADS and/or vouchers or if they will be away from the computer?
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 ofpre-numbered paper TADS for use in emergencies?
11. Does the clinic maintain a supply of blank manual vouchers for use in emergencies?

I Comments
I
I

45

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
'
I

Areas of Review

Yes No NA

12. Does the clinic maintain a supply of paper TAOs, 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 FNAME" entries).
16. In the VOUCHER MESSAGE/MAX PRICES table "are the not to exceed prices" current?
17. Do the backup diskettes contain all of the 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 acknowledgment dates for TAD and Voucher Patches posted?
20. Is this ATVS version in use this current release?

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 ofthe Local Agency and State Agency?

Comments I
I
I
Comments

46

GA WIC PROCEDURES MANUAL FY'97

----

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 ofthe 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 vendor and give the appropriate training, as stated in the Vendor Section of the FFY' 96 Procedures Manual (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

I

to the State WIC Office?

E. If a vendor was terminated, were the vendor stamps returned to the State WIC Office with a copy ofthe Vendor Input/Registration Form within 30 days?

1. If the stamp was not retrievable, was a Vendor Input/Registration Form submitted to the State WIC Office with a statement noting the reason why the stamp was not returned?
I
F. Has a Vendor Agreement (Attachment VN-4) been signed between the Local Agency and the new vendor?

Attachment MO-l (cont'd)

47

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
'
I I

Areas of Review

Yes

1. 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 retrieve the 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 ofthe 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 1 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 final training session in the District/Unit?

1. 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?

I. What percentage of a district's vendors were visited during the past two Federal Fiscal years?

1. 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?

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?

No NA

Comments

I

~
I

48

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

-..RT VI FINANCIAL MANAGEMENT

Guidelines

Areas of Review

A. Review of Previous Audit Findings

Yes No NA

1. Has an audit been performed recently by an independent accounting finn?

'

2. Were any findings noted? (If yes, attach a copy

I

ofthe audit containing these findings.)

i
3. Were measures taken in response to these

findings?

B. Budgets

1. Are the appropriate WIC budgets and revisions for the current fiscal year available for review?
2. Are budgets revised and submitted in a timely
manner when allocations are made?
3. Are copies of contracts attached?
c. Expenditures

1. Are expenditure reports submitted in a timely

i

manner?

I

2. Are expenditures for nutrition education

I
I

monitored to ensure expenditure levels are a

i

minimum of one-sixth (116) oftotal administrative

expenditures?

D. Generally Accepted Accounting Practices

1. Are accounting records maintained by WIC paid staff or by the district accounting personnel?

i

2. Does the local agency maintain a separate account

I
' '

for WIC funds?

If not, is adequate documentation maintained to identify revenues and disbursements for the WIC Program?

'
I
i

3. Are revenues for the WIC Program deposited in
an interest bearing account?

I

I

4. Are source documents protected from damage or

I

unauthorized access?

Comments
'

49

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

I Guidelines
'
I
I
!
I ...
I

Areas of Review

Yes

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?
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?
11. Is the preparation of checks independent from the approval of invoices?
12. Are the receiving duties independent ofthe 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 ofsigning and marked "paid" to prevent duplication of payment?
15. Are records maintained for the required length of time? (3 years plus current)
E. Documentation ofTime

1. 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 nonWIC paid staff?
F. Equipment

1. Are proper equipment inventory records maintained?

No NA

Comments

50

GA WIC PROCEDURES MANUAL FY'97

r -
i \:.atde mes

Areas of Review

Attachment MO-l (cont'd)

Yes No NA

Comments

2. Has a physical inventory been conducted within

i '
i

the last year?

3. Do inventory records indicate:

I

a. Inventory decal number

I

b. Description of equipment

i

c. Serial number (if applicable)

I

I

d. Location of equipment

I

e. Date of purchase

I

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?

I

5. Are the proper procedures followed to dispose of

L

obsolete or damaged equipment?

I I

6. Are the proper procedures followed when

I

equipment is discovered, lost or stolen?

I

H. Indirect Costs

1. 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?

PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING- OON

Guidelines

Areas of Review

Yes No NA

CoiQments

Corrective Action

I. FOOD PACKAGE ASSIGNMENT

A. List title(s) of competent professional authorities (CPA's) who assign food packages for participants:

51

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action
'
Corrective Action
Recommendation Recommendation

Areas of Review

Yes No NA

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)

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.)

Comments I

52

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

..Jaidelines
Recommendation
Recommendation Recommendation Recommendation Recommendation Recommendation
r-
Recommendation Corrections Action Corrective Action Corrective Action
Corrective Action

Areas of Review
II. Nutrition Education

Yes No NA

A. Training (The following questions must be asked separately ofthe WIC/Nutrition Coordinator and the Clinical Coordinator.)

1. At the time ofthe program review, please provide the reviewer with a summary ofall nutrition in services/ training attended by local staff since the last review.

List provided?
2. How are district/clinic in services 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:

a. the training sessions themselves? b. training effectiveness over time?
B. Paraprofessional Training

l. Are paraprofessionals used to certify participants?
2. Are paraprofessional used to provide secondary
nutrition education contacts?
3. Has the training plan for paraprofessionals been
approved by the Office ofNutrition?

Ifyes, the date:
4. Have all lesson plans for training
paraprofessionals been submitted to the Office of Nutrition for approval?

Ifno, please provide reviewer with lesson plans at the time of review.

Comments

53

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Corrective Action
'
Corrective Action
Corrective Action
Recommendation Corrective Action Recommendation Recommendation

Areas of Review

Yes No NA

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 ofNutrition by April 1 (of appropriate year)?

Ifyes, date:

If no, date received:

Not Received:

NAif review prior to April! ofthe appropriate year.
2. Was an annual progress report received by the Office ofNutrition by December 1?

Ifyes, date: _ _

If no, date received:

Not received: - - -
3. Give status of each Nutrition Education Plan
objective:
D. Participant Nutrition Education Contacts

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?

Comments

54

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

..suidelines
1 Recommendation
' '
I
!
i
i
Corrective Action

I

I
i

Recommendation

i Recommendation

Recommendation
,, I
Corrective Action

Recommendation ! ' Corrective Action

:
Corrective Action

' ;

!

I
I

Corrective

Action

I

I

Areas of Review

Yes No NA

4. Since the last program review, has the system for
providing and/or documenting nutrition education contacts changed?

If yes, 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

I. Who approves nutrition education materials and forms not provided by the State?
2. What method(s) is/are used to evaluate nutrition
education materials?
3. A list of all approved nutrition education
materials and a copy of those not available through Central Supply are to be provided to the Office ofNutrition. List provided?
4. Are materials provided which meet the needs of
specific population groups?
5. Are inappropriate nutrition education materials available for participant's use?

I Comments I

55

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines

Areas of Review

m!~@J~ffimlJ.W.t

~tf.~~e.~~~~

C<ior<lliiator ............ ;.,

;.;;,.,~~;:..'.:.

'

III. Breastfeeding Promotion and Support
This section should be addressed with both the WIC coordinator and the local agency breastfeeding coordinator.

A. Breastfeeding Coordinator

Yes No NA

Recommendation
'
Recommendation @:@;~S!f\WJ~~~9.p
I Recommendation Recommendation Recommendation

1. What are the names and credentials/ qualifications ofthe 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
ofthe breastfeeding coordinator:
6. Does the breastfeeding coordinator provide individual counseling?
If yes, please answer the following:

a. Where does individual counseling take place?

Recommendation

Clinic _ _Phone _ _Participant's Home _ _Hospital _ _Other (Please specify)
b. Individual counseling is provided to:

Prenatal Women _ _Breastfeeding Women

Comments 1

56

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

I ..,.tlidelines
Recommendation
Recommendation
I
i
!
Recommendation

I Recommendation
I
I
I Recommendation
Recommendation

i

I rrorrectivW~ction

Newst a l i _..,_ :.~V:..

.'. ---~~~~-:-::.::.:->

....;._,.,_.,,.,./ ' ~-~- .;.'..

Corrective :Kction . . .. '. '': ...~

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

99ff.~f!!~I\m;9"B
i '

Areas of Review
c. How is individual counseling documented?

Yes No NA

_ _Central File _ _Participant health record _ _Other (please specify)
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 _ _Prenatai/Breastfeeding Class _ _Other (Please specify):
2. Describe the process for individual contacts being
provided (when, by whom, documentation):
3. Describe the process for provision of prenatal
classes to include breastfeeding (when, by whom, documentation):
c. Training

1. Please provide, at the time ofthe review, a list of:

_ _Training attended by breastfeeding coordinator

_ _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?

If yes, describe how this is done and who provided the in-depth counseling.
?f.! P.~.~~1J.~~,~~H2~~~~~~,:~ff<f~~.!9.:!~~,-~
cl1.g:;~o.m>!!~@:m~n~.:}!l?l''.1i;}!~JEf
g~~g;

Comments
'

57

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

I
I
! Guidelines
Recommendation

Areas of Review
5. Other

Yes No NA

Comments

'

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 ofbreastfeeding, nutrition education and nutrition materials being implemented in the Local Agency:

c. What requests of the District/Local Agency have ofthe
Office ofNutrition staffto assist in implementing Nutrition Education and Breastfeeding Plans and providing nutrition services?

v. CLINIC OBSERVATION: INDIVIDUAL
NUTRITION EDUCATION SESSION

..

DATE:

CLINIC:

REVIEWER:

Participant status:

p BN Ic

Participant priority: I II III IV v VI

Participant risk factors: ABCDEFGHIJKL MNOPQRSTUVWXYZ

Time estimate for total contact:

Corrective Action

Time estimate for NE contact: A. Nutrition Education

I Corrective Action
Corrective Action

I. 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?

58

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

uuidelines
Corrective Action Corrective Action

Recommendation

Corrective Action

! Recommendation
i
I
i Recommendation
i
i Recommendation

i Recommendation
:
'
I
,I

l
I

~ctive Action

L

Corrective Action

Recommendation

Recommendation Recommendation
I Recommendation
IRecommendation

Areas of Review
4. Does NE relate to diet recall/assessment?
5. Does NE include WIC foods and their
relationship to participant risk?
6. Does NE include total food intake and its relationship to participant risk?
7. Does NE follow Nutrition Guidelines for Practice?
B. Communication

Yes No NA

I. Does counselor invite questions?
2. Does participant ask questions?
3. Is session conducted in language participant
speaks/understands?
c. Materials (includes posters, flip charts, food models,
pamphlets, etc.)
'
I. 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?
2. Is there seating for counselor?
3. Is there seating for participant and others in
session?
4. Is space quiet enough to talk normally?
5. Is the view ofthe participant/counselor obstructed by materials on the desk or by the seating arrangement?
E. Additional Comments

I Comments
I
I

59

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines

Areas of Review

Yes No NA

VI. CLINIC OBSERVATION: GROUP NUTRITION EDUCATION SESSION

'
DATE:

CLINIC:

REVIEWER:

Topic:

Composition of Group (prenatal, breastfeeding mothers, caregivers of infants, etc.):

Comments

Recommendation
Recommendation
I Recommendation
Corrective Action Recommendation Recommendation
I Recommendation
Recommendation

Expected Attendance:

Actual Attendance:

No show rate (calculate percent):

%

Time Estimate for NE Contact: A. Integration

1. Session conducted to connection with:

Certification Voucher Pickup Other Appointment Specify
B. Nutrition Education

1. 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

1. Does instructor invite questions? 2. Do participants ask questions? 3. Does instructor respond to questions? D. Materials/Media

1. Is session conducted in language(s) participants speak?

60

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

r Guidelines

i
I
;

Recommendation

!

Recommendation

I I Recommendation
I
! Corrective Action
i
I

Recommendation

I !

Recommendation

I Recommendation
I
I

Recommendation

Recommendation

Recommendation

D -~ommendation

Areas of Review
2. Are materials/media in language(s) participants
speak?
3. Media used:

Yes No NA

Film/Filmstrip Slidefrape Show Video Tape Poster/Flip Chart Food Models Pamphlets Other Specify:
4. Are print materials related to information covered
during session?
E. Staff

Session conducted by:

Nurse Nutritionist Paraprofessional Other Specify:
F. Evaluation of Knowledge and Satisfaction

1. Any evaluation of participant's nutritional knowledge base?
2. Any evaluation ofknowledge 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?

Comments
'

61

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

Guidelines
Recommendation Recommendation. , Recommendation
Recommendation

Areas of Review
4. Can participants see instructor? 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

Yes No NA

Comments

Recommendation
Recommendation Recommendation Recommendation Recommendation

VII. CLINIC OBSERVATION: QUESTIONS FOR CLINIC STAFF (Must be completed in at least one (I) clinic)

Date

Clinic

Reviewer

Staff person interviewed: Nurse Nutritionist
Paraprofessional
A. Is the Nutrition Guidelines for Practice used as a reference?

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?

62

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

1.

ANTHROPOMETRIC EQUIPMENT

Date._ _ _ _ _Clinic._ _ _ _......;Reviewer._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

OBSERVATIONS

S-Satisfactory U -unsatisfactory
#1 #2 #3

1.

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

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

COMMENTS

63

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

IX.

HEMATOLOGIC EQUIPMENT

Date--------- - -Clinic--------~Reviewer ----------------------------------
A. ' Type of equipment used (brand/model) for hgb. or hct.

B. 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?

64

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

CLINIC OBSERVATION: ANTHROPOMETRIC MEASUREMENTS

Date Observe

at

least

one

Clinic (1) standing

height,

sRtaenvdieinwgerw--e-ig-h-t-,-r-e-c-w-n-b-e-n-t-l-e-n-g-t-h-, -a-n-d-i-n-f-a-n-t-s-c-a-le--w-e-i-g-h-t.--

Woman

Child

Status:

Age:

--

: Woman/Child (Standing Height)

Yes

No

Yes

No

!

i 1.

Participant measured without shoes

2.

Proper stance used for reading measurement

.. .

: 3.

Headboard is level, touches top ofhead

. -.

I

; 4.

Correct angle used for measurement

---

i 5.

Measurement taken to nearest 118 inch

: 6.

Two (2) measurements taken

I
! Woman/Child (Standing Weight)

i
:

1 .

Participant dressed in minimal clothing

Yes

No

....

Yes

No

---

i 2.

Scale zeroed, prior to measurement

"

3.

Correct angle used for reading measurement

4. '1

Weight measured to nearest 114 pound

,I _

i

Two measurements taken

Infant Age:

Child Age:

Infant/Child (Recumbent Length)

Yes

No

II I.

Participant measured with minimal clothing

Yes

No

: 2.

Body straight, lined up with measuring board

i

: 3.

Head is against headboard throughout measurement

4.

Footboard resting firmly against heels

~-----------------------------------------------+--------+--------+--------+---------

- 5.

Correct angle used for reading measurement

~----------~-----------------------------+------~------~-------r-------

! 6.

Measurement read to nearest 118 inch

~-----------------------------------------------+--------+--------+--------+----------

i 7.

Two (2) measurements taken

i Infant Child (Infant Scale Weight

Yes

No

I

II 1.

Participant dressed in minimal clothing (without wet diaper)

I

I 2.

Scale zeroed, prior to measurement

Yes

No

i 3.

Correct angle used for reading measurement

4 .

Weight measured to nearest \1: ounce

I
i -

Two (2) measurements taken

65

GA WIC PROCEDURES MANUAL FY'97

Attachment MO-l (cont'd)

XI.
:
RECORD REVIEW District Clinic Date

' ...;;.....

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

....... ,.

;~--..:. :.-..<;-, .'-~-..-... . ...

f . r

' .;.:.h ;-;-.:-:-:-:..:-;:-,:-:-:-:.

1.

Participant Status Recorded (Women Only)

2.

Medical Data Date

3.

Length/Height Recorded

4.

Weight Recorded

5.

Hct/Hgb Recorded

6.

Age Recorded

7.

Length/Height Plotted

8.

Weight Plotted

9.

Weight for Length/Height Plotted

10.

Diet Intake Recorded

11.

Diet Summary 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

I 19.

Food Pkg. Number

20.

Referrals/Enrollment Documented

I 21.

Today's Date

I
I 22. Professional's Signatures & titles (Cert. Form)

23.

Primary NE Contact, Current Certification

I
24. Secondary NE Contact, Current or Prior Cert.

25.

Breastfeeding Encouraged

26.

High Risk Follow-up Documented

-l
T 0 T A L
I
I I
I I I
I I
I
i
I
I
I
I
I
I
I
I
~

66

..

GA WIC PROCEDURES MANUAL FY '97 TABLE OF CONTENTS

I. Introduction ...................................................... BF-1

IT. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BF- 1

ill. State Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 BF- 2

A.

Breastfeeding Coordinator ... BF- 2 0

0



0



0



0



B. Breastfeeding Promotion, Education and Support Responsibilities ....... BF- 2

IV.

Local Agency ......... BF- 4 0



0



0

0



0



0



0

0



A.

Breastfeeding Coordinator . BF- 4 0

0

0

0



0



0



0



0



0



B. Breastfeeding Promotion, Education and Support Responsibilities ....... BF- 4

C.

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 BF- 6

D. Breastfeeding Promotion, Education and Support Plan ................ BF-6

V. Participant Education ............................................... BF-7

A.

Participant Education Requirements ... BF- 7 0



0

0





B.

Documentation ofBreastfeeding Services

..... BF-9 0



0



0



VI.

Participant Referral .... BF-10 0



0



0



0

0



0



A.

Referrals

. 0















0



0























0























0



0





BF-10

B.

Documentation

0



0



0



0



BF-11 0



VIT. Breastfeeding Materials and Resources ................................. BF-11

A.

Printed and Audiovisual Materials .... BF-11 0



0



0



B.

Breastfeeding Equipment and Supplies

......... BF-11 0



0



GA WIC PROCEDURES MANUAL FY '97
Vlll. Allowable Costs for the Promotion and Support ofBreastfeeding .............. BF-13 A. Minimum Expenditure Requirement .............................. BF-13 B. Allowable Breastfeeding Promotion and Support Costs ............... BF-13 C. Documentation of Costs ....................................... BF-15
IX. Documentation ofBreastfeeding Rates .................................. BF-15 A. Documentation ofWIC Type ................................... BF-15 B. Documentation ofWeeks Breastfed .............................. BF-16
Attachments BF-1 Position Paper on Breastfeeding ....................................... BF-18 BF-2 Merit System ofPersonnel Administration, State of Georgia
Class Title: Senior Public Health Educator- Lactation Consultant ............. BF-19 BF-3 Geor~a Gain Proposed Job Description: Breastfeeding Coordinator ........... BF-21 BF-4 Guidelines for Breastfeeding Promotion and Support
in the WIC Program ................................................ BF-24 BF-5 Breastfeeding Resources Recommended by the Office ofNutrition ............. BF-37 BF-6 Allowable and Unallowable Costs for the Promotion and
Support ofBreastfeeding ............................................ BF-40 BF-7 Issues to Consider When Providing Breast Pumps ......................... BF-41 BF-8 Status Change from Prenatal to Breastfeeding and Assignment
Priority to Breastfeeding Mother and Infant .............................. BF-44 BF-9 Key for Entering Weeks Breastfed ..................................... BF-47
ii

GA WIC PROCEDURES MANUAL FY '97
I. INTRODUCTION
This section of the Procedures Manual defines the concept of breastfeeding promotion, education and support; and explains the requirements for providing lactation services to WIC Program participants.
Health professionals recognize that, in almost all circumstances, breastfeeding is the optimal method for ensuring proper infant nutrition, while simultaneously benefiting the lactating mother. The advantages of breastfeeding range from biochemical, immunological, and endocrinologic to psychosocial, developmental, sanitary and economic. Human milk contains the ideal balance of nutrients, enzymes, immunoglobulins, anti-infective agents, anti-allergic substances, hormones, and growth factors. Further, breastmilk changes to match the changing needs of the infant. Breastfeeding provides a time ofintense maternal-infant interaction. Lactation also facilitates the physiologic return to the pre-pregnant state for the mother. 1
Public Health staff have a responsibility to provide services designed to optimize the health 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-1) a sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.
IT. DEFINITIONS
Breastfeeding promotion, education and support are components of a process through which individuals gain the understanding, skills and motivation necessary to be able to select breastfeeding as the preferred method of feeding, as well as to initiate and maintain breastfeeding for a significant period oftime.
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.
Relactationfmduced lactation after a period of not breastfeeding, or by a woman who is not the biological mother ofthe infant, also qualifies the woman as breastfe((ding.
1 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department ofHealth and Human Services, 1990.
BF-1

GA WIC PROCEDURES MANUAL FY '97

lli. STATEAGENCY

A. Breastfeeding Coordinator

The responsibility for coordination of Statewide WIC breastfeeding activities

is vested within the Georgia Department of Human Resources, Division of

Public 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 of this 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:

1. Develop, implement and evaluate the State Breastfeeding Promotion, Education and Support Plan. Periodically review ~d evaluate the Plan, and make appropriate revisions as necessary.

2. Develop guidelines for local agency Breastfeeding Promotion, Education and Support Plan development. Review each plan and provide feedback.

3. Monitor the progress of local agency breastfeeding promotion, education and support plans on a periodic basis through on-site visits and reports.

4. Evaluate breastfeeding promotion, education and support services of all local agencies.

5. Develop and implement a plan for providing training and technical assistance for Competent Professional Authorities (CPA's), paraprofessional staff and clerical staff at local clinics. Training and technical assistance provide CPA's with current information on the management of normal breastfeeding issues and special problems in lactation. It provides all staffwith an understanding ofthe importance ofpromoting, and ways to promote, breastfeeding in a clinic setting.

6. Identify and develop resource and education materials for use by local

BF-2

GA WIC PROCEDURES MANUAL FY '97
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 ofthe participants.
7. Coordinate WIC breastfeeding promotion, education and support activities with related programs and professional groups such as hospitals, private medical organizations, the Cooperative Extension Service, professional organizations, advisory committees, La Leche League and other breastfeeding support and advocacy groups, private lactation consultants, etc.
8. Develop and implement procedures to assure that encouragement to breastfeed is offered to all prenatal participants, unless medically contraindicated.
9. Perform and document evaluation of breastfeeding promotion, education and support activities for each local agency on an annual basis. The evaluations shall include an assessment of participant's views concerning the effectiveness of the education which they received.
10. Establish standards for participant contact that ensure adequate breastfeeding education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant breastfeeding education contacts.
12. Establish breastfeeding promotion, education and support standards 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-
BF-3

GA WIC PROCEDURES MANUAL FY '97

appropriate 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 breastfeeding 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

or assure that an individual is

to fill this oo,s1uon.

2. It is recommended that the breastfeeding coordinator work across program lines to provide breastfeeding services, thus increasing opportunities for all current and potential WIC participants to be reached. This will also serve to integrate services, and assure that all clinic staff receive appropriate training and deliver consistent information on breastfeeding.
3. It is recommended that this position be designated as a full-time position, in order to facilitate coordinating services throughout the local agency and across program lines, and to adequately meet Federal requirements.
B. Breastfeeding Promotion, Education and Support Responsibilities
The Georgia WIC Program is committed to the implementation of the Guidelines for Breastfeeding Promotion and Support in the WIC Program, developed by the National Association of WIC Directors (NAWD) Breastfeeding Promotion Committee (Attachment BF-4). The local agencies are encouraged to use the Guidelines in carrying out the following breastfeeding responsibilities:
BF-4

GA WIC PROCEDURES MANUAL FY '97 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 local agency plan of activities (See IV.D., below). BF-5

GA WIC PROCEDURES MANUAL FY '97
C. Training
I. Orientation
In addition to the training that is to be provided by the local agency to new staff, during orientation, staff should attend the three (3) levels ofthe Competency Based Nutrition Skills Workshops during their first twenty-four (24) months of employment. The Competency Based Nutrition Skills Workshops are conducted by the Office ofNutrition. These workshops provide WIC competent professional authorities (CPA's) with current information on nutrition issues, and include the topic ofbreastfeeding 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 of developing and updating skills and knowledge in lactation management.
b. All breastfeeding training and continuing education activities conducted or attended by local staff must be recorded and kept on file by the local agency. The file should include the names and titles of the workshop participants, and the titles and dates ofthe workshops(s~e 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 shall submit to the State, by April 1 of every year, a Plan of Activities based on the State Plan objectives, and recommendations for additions or changes to the State Plan.
BF-6

GA WIC PROCEDURES MANUAL FY '97
a. The local agency Breastfeeding Plan must include:
1) A listing of State Plan objectives that will be addressed bythelocalagency
2) Action steps, including activities and methods for each objective selected
3) Resources to conduct each objective 4) Milestones ofactivities for each objective 5) Evaluation design to detennine the extent to which the
outcome is commensurate with the State objective
b. The local agency Plan must address, at a minimum, the Federal requirements: prenatal encouragement to breastfeed, establishing a positive clinic atmosphere, incorporation of breastfeeding training into staff orientation, 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 ofthe Breastfeeding Plan can be found on Attachments NE-1 and NE-4, with exclusion ofthe Needs Assessment.
2. Breastfeeding Plan Update
a. The Breastfeeding Plan Update is a progress report and must be submitted to the Office of Nutrition by April 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
BF-7

GA WIC PROCEDURES MANUAL FY '97
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 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.
As stated in the Healthy People 2000 National Health Promotion and Disease Prevention objectives for breastfeeding, breastfeeding is not appropriate for infants whose mothers use drugs illicitly, or who receive certain therapeutic or diagnostic agents such as radioactive
elements and cancer chemotherapy.2 Women who are mv 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 (I) year postpartum, 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. lt~41-mi.:il.n:lmi1f.Irllm!B:m~iiEt~~~.~n.i:iP.IP:rl~mt.:f,
All staff should be trained to teach hand expression of breastmilk. However, if a staff person is not skilled in this area, a referral should
2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department ofHealth and Human Services, 1990.
BF-8

GA WIC PROCEDURES MANUAL FY '97
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 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 participant 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 (Subjective- Objective- 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 of time, home visits are the recommended method for providing breastfeeding education contacts.
11. Local agencies are also encouraged 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
BF-9

GA WIC PROCEDURES MANUAL FY '97
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 breastfeeding discussed with the participant (e.g., barriers to breastfeeding, emotional and nutritional advantages of breastfeeding, positioning, etc.).
b. The POMR ~roblem Oriented Medical Record)/SOAP note format is the recommended method ofdocumentation. A flow sheet may be used as long as it contains all components of a 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 description with the date, lesson objective(s) and the original signature ofthe staffconducting the class. A description ofthe local agency's method of documentation must be submitted for approval, prior to implementation.
2. Missed appointments for breastfeeding education contacts and the refusal of a participant/caregiver to receive breastfeeding education must be documented in the participant's health record.
VI. PARTICIPANT REFERRAL
A. Referrals
1. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.
2. Local agencies are encouraged to identify and develop a list of breastfeeding resources for prenatal and breastfeeding women. This list may include hospital staff, physicians, local support groups (both informal and organized, such as La Leche League), public health staff with expertise in handling breastfeeding questions, sources for breastfeeding pumps, peer counselors, etc.
BF-10

GA WIC PROCEDUJ,U:S MANUAL FY '97
B. Documentation Referrals to and enrollment in other health services and programs must be documented in the participant's health record. A decision not to refer or a refusal by the participant must also be documented.
Vll. 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). ~lllli.f.lll!!llill:illilUl\jgJiy~~jj
Attachment BF-5 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 generally 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. BF-11

GA WIC PROCEDURES MANUAL FY '97
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 ~~ilii.~~iii~nii!Bili~~~P~91~i!Iand in the Administrative Responsibilities section of the Procedures Manual. Attachment BF-6 provides a list of allowable and unallowable costs, as specified in the Federal Regulations.
2. Breast Pumps
Local agencies are encouraged to have a supply of manually-operated and electric pumps on hand for situations that merit their use. It is neither necessary nor desirable to give breast pumps to every breastfeeding or potential breastfeeding mother. Some situations in which availability of a breast pump may be necessary to assure continuation of milk production are:
a. Mothers who have temporary breastfeeding problems, such as engorgement. These are situations in which hand expression or a manual pump may be all that is needed.
b. Mothers who are having difficulty in establishing or maintaining an adequate milk supply due to maternal illness or a premature~sick infant.
c. Mothers with inverted/flat nipples who are having latch-on problems.
d. Mothers attempting to build their milk supply for any reason.
e. Mothers choosing to express breastmilk for missed feedings due to work, school, maternal hospitalization or iftemporary wearung IS necessary.
Breast pumps are not a direct Program benefit that State agencies are required to provide but rather are aids that may be offered to certain WIC participants to facilitate breastfeeding. 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-7.
BF-12

GA WIC PROCEDlJlffiS MANUAL FY '97 3. Instructions for Breast Pump Use Local agencies with breast pump loan and give-away programs must establish written policy and procedures regarding appropriate use, and instructions to be provided to breast pump recipients. The following must be included in the policy and procedures: a. A trained, designated staff person is to provide instructions to the breast pump recipient on the proper use, assembly, and cleaning of the breast pump. b. The participant recetvmg the breast pump should be able to demonstrate the proper usage of the breast pump before leaving the issuing facility. c. Follow-up within a 24-hour period is recommended, in order to assure that the pump is operating correctly and that the mother is using it properly.
BF-13

GA WIC PROCEDURES MANUAL FY '97 gatmi~i~ 11.~!1:
W:f:i~~:g~ ~:;:
s~i~~:::ifi{titlffiis~ %1:
lfaiearu~::~np:::sifillem~
g1 miIit!Elirl.9rlll11illlrlllt~IIFR1~ll!:lif.\E!.~inl:::n.llli~
2)1
MpmtB11Hii\ina::sRniu~;a~ 1J.~g;1
BF-14

GA WIC PROCEDUl,U:S MANUAL FY '97
IX. DOCUMENTATION OF BREASTFEEDING RATES The Georgia WIC Program documents breastfeeding rates by two different methods: percentage ofwomen who are certified as breastfeeding (WIC Type B), and selfreported information on weeks breastfeed (initiation). It is important that documentation be accurate in both instances since they have a major impact on administration ofthe 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 B.ljjlfyp~)Rlllland BF-15

GA WIC PROCED{Jl.U:S MANUAL FY '97

breastfeeding women a1:::1fm~::1J. 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.

..

. .... .

prenatal woman gives birth and is being

certified as breastfeeding, within six weeks postpartum.

2.

3. ~~sn~.~::~~:~~d.~g:::$~~fil.~::~-g:~t,;ti~~~~i~fi.. 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 ll. on page BF-1).
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.
BF-16

GA WIC PROCEDURES MANUAL FY '97 It is critical that all staff who complete The WIC Assessment/Certification Forms and the Turnaround Documents be instructed on the importance of, and the process for, accurate documentation of weeks 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 of time breastfed must be entered in weeks. When the answer to the question is given in days or months, this information must be converted to weeks. See Attachment BF-9 for appropriate codes to use for weeks breastfed.
BF-17

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-1

POSITION PAPER ON BREASTFEEDING
Ifthe 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 :first food for the human infant. In addition to the nutritional benefits for the infant, this method offeeding offers unique physiological and psychological advantages to both the mother and the infant Every infant, therefore, should receive the benefits ofthis ideal choice for infant feeding. This paper presents the recommendations of the State of Georgia for encouraging breastfeeding and defines the advantages of breastfeeding for the health ofmothers and infants.
No formula, no matter how "humanized", can take the place of human milk. Decreased infant mortality and optimtun infant health are the most important goals of the Division ofPublic Health. Breastfeeding can contribute significantly to the achievement of these goals because:
* breast milk provides an ideal balance ofnutrients for the human infant * the nutrients in breast milk are easily absorbed and digested
* breast milk contains immune factors and anti-infective properties that protect against infections
* breastfeeding allows the satiety mechanism in the infant to develop naturally * infants who are breastfed have fewer allergies * breastfeeding permits increased bonding between mother and infant * breast milk is safe, sanitazy food
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. Based on the World Health Organization/United Nations International Children's' Fund (WHO/UNICEF) 1979 meeting on Infant and Young Child Feeding, the WHO 1981 Resolution and the recommendation ofthe American Academy ofPediatrics Committee on Nutrition, the Georgia Department ofHuman Resources recommends that:
* breast milk be the "house formula" in all hospitals in Georgia where maternity services are
offered
* all expectant parents be informed of the numerous advantages (both to infant and mother) of
breastfeeding.
* every expectant mother receive practical information on how to initiate and maintain lactation. * obstetrical procedures and practices be consistent with the policy ofpromoting breastfeeding. * breastfeeding be initiated as soon as possible, preferably during the first hour after birth. * every hospital permit and encourage rooming-in and on-demand feeding ofbreastfed infants. * infant formulas not be marketed or distributed in ways that may interfere with the protection and
promotion ofbreastfeeding.
* places ofbusiness, including government offices, facilitate the maintenance oflactation through
liberalized policies that would promote breastfeeding.
All the available knowledge indicates that breastfeeding is the best choice for infant feeding and should be promoted for mothers and infants ofthe State. Breast milk as this choice for infant nutrition will promote optimum health for future generations of Georgians.
~
P;I~IIJ. 'll&elwo, M.D. Dlrlc,.r
hW... .r I'IIUc Hallll

BF-18

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-2

MERIT SYSTEM OF PERSONNEL ADMINISTRATION- STATE OF GEORGIA

Class Title: SENIOR PUBLIC HEALTH EDUCATOR-LACTATION CONSULTANT

The examples ofwork given are illustrative of the duties assigned to positions of this class. No attempt is made to be exhaustive. The intent of the listed examples is to give a general indication of the levels of difficulty and responsibility common to all positions of this class.

The standards for training and experience express the minimum background necessary as evidence of an applicant's ability to qualify for positions of this class. Unless otherwise stated, the Applicant Services division may allow substitution of appropriate education or experience for the training and experience minimum listed.

DEFINITION

Under direction, performs work of moderate difficulty in planning and implementing breastfeeding education activities related to public health programs; and performs related work as required.

EXAMPLES OF DUTIES

I. .Coordinates breastfeeding promotion project. Writes, revises and evaluates the district's breastfeeding services.

A. Establishes 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 staff development.

C. Responsible for keeping daily communication sheets regarding telephone calls, correspondence, patients seen, meetings and work related to breastfeeding funds.

II. Promotes breastfeeding services as an integral part of perinatal care.

A. Encourages all prenatal women on initial visit to breastfeed by providing an array of educational material and counseling.

B.

Provides additional breastfeeding counseling to prospective breastfeeding women

during the last trimester through breastfeeding classes and/or individual counse<ling.

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.

BF-19

GA WIC PROCEDURES Mf\NUAL FY '97

ATTACHl\1ENT BF-2, cont'd

D. Develops and implements continuing education and support networks through a variety ofmethods, such as support groups, peer counselors, etc.

E. Supervise and train peer counselors.

F. Has ability to commwricate effectively in writing, including grant proposals.

ill. Evaluates effectiveness ofbreastfeeding 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.

MINIMUM QUALIFICATIONS: NECESSARY KNOWLEDGE, SKILLS, AND ABILITIES

Considerable ability to assess the effectiveness and needs of a 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 ofinstructional programs to the general public and to other health specialists.

Good knowledge ofeducational program development and implementation as related to the preparation ofhealth education displays, lectures, written material, and classroom programs; of data collection and evaluation techniques appropriate to the assessment of the breastfeeding program.

Good working skill in commwricating effectively with the professional staff, general public and paraprofessionals; 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 ofa 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.

BF-20

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-3

JOB CODE: JOB TITLE:

GEORGIA GAIN PROPOSED JOB DESCRIPTION
E0707% BREASTFEEDING COORDINATOR

GENERAL SUMMARY

Under general supervision, plans, develops, implements and evaluates strategies for promoting and supporting breastfeedillg among the high risk, low income population, especially prenatal/breastfeeding women and infants.

RESPONSIBILITIES AND STANDARDS Responsibility Number I (All) Develops long and short-term goals for breastfeeding promotion and supports activities for the district.

STANDARDS:

I.

Works closely with the supervisor to develop an appropriate District Breastfeeding Promotion and

Support Plan.

2.

Coordinates breastfeeding services among all clinic sites to ensure efficiency of services provided.

3.

Accurately interprets federal/state regulations to ensure adherence to these.

4.

Makes sound and defensible recommendations to the supervisor regarding the breastfeeding budget.

5.

Develops continuing education, support networks for mothers and networks for professionals in

breastfeeding promotion and support.

R__e__s_p_o__n;.s._i_b_i_l_i_t_y__N__u_m___b_e_r__2__(_S__o_m___e_)______________________________________________.;.._____________________________
Implements breastfeeding promotion and support plans, to include staff development, community networks and services to clients.

STANDARDS:

1.

Provides inservice education, materials and/or needed equipment for staff development in a timely

manner.

2.

Establishes a good working relationship with community health centers and/or hospital staff to assure

continuity ofbreastfeeding services to clients.

3.

Serves as the District's primary resource person regarding breastfeeding education and support

by providing prompt responses to inquiries.

4.

Provides direct services to clients through prenatal classes, individual instruction, referral for

appropriate case, telephone consultations according to established laws and guidelines.

5.

Coordinates pump loan program to ensure maximum usage of available pumps and instructs

both staff and clients on use of breast pumps as needed.

BF-21

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-3, cont'd

6.

Serves as primary resource person to health department staff regarding current

recommendations and information in breastfeeding management.

' Responsibility Number 3 (All)

Works closely with the supervisor to evaluate the effectiveness ofbreastfeeding program activities.

STANDARDS:

1.

Monitors reports to accurately determine breastfeeding rates by county, district, and state.

2.

Writes the annual progress report on the breastfeeding promotion and support plan by providing

appropriate input in a timely manner.

3.

Maintains necessary reports and data for the purpose of documenting incidence and duration of

breastfeeding, client-centered activities, activities conducted with other agencies, community

groups and local hospitals, and training conducted.

Responsibility Number 4 (All) ---------------------------------------------------------------------<:reates
and maintains a high performance environment characterized by positive leadership and a strong team orientation.

STANDARDS:

1.

Defines goals and/or required results at beginning of performance period and gains acceptance

of ideas by creating a shared vision.

2.

<:ommunicates regularly with staff on progress toward defined goals and/or required results,

providing specific feedback and initiating corrective action when defined goals and/or results

are met.

3.

<:onfers regularly with staff to review employee relations climate, specific problem areas and

actions necessary for improvement.

4.

Evaluates employees at scheduled intervals, obtains and considers all relevant information in

evaluations and supports staff by giving praise and constructive criticism.

5.

Recognizes contributions and celebrates accomplishments.

6.

Motivates staff to improve quantity and quality ofwork performed and provides training and

development opportunities as appropriate.

Responsibility Number 5 (All)

Maintains responsibility for personal professional continuing education to enable application of current professional practice.

BF-22

GA WIC PROCEDURES M,ANUAL FY '97

ATTACHMENT BF-3, cont'd

STANDARDS:

I.

Participates in professional workshops, seminars, nutrition staff meetings and other inservices

as scheduled. Summaii.zes relevant information received in the training sessions and shares with

other staff either in verbal or written form.

2.

Remains knowledgeable and up-to-date in the field of nutrition through reading nutrition and

medical journals and textbooks.

3.

Maintains CPR certification and proficiency by renewing certification bi-annually.

BF-23

GA WIC PROCEDURES M;ANUAL FY '97

ATTACHMENT BF-4

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 and task-appropriate training on breastfeeding as the preferred method ofinfant feeding.
GUIDELINE#2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and endorse breastfeeding as the preferred method ofinfant feeding.
GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations.
GUIDELINE#4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials, and outreach efforts.
GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.
GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.
GUIDELINE #7
BF-24

GA WIC PROCEDURES M;ANUAL FY '97

ATTACHMENTBF-4, cont'd

Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their 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 management techniques to

encourage and support the breastfeeding mother and infant



appropriate use ofbreastfeeding education materials



identification of individual needs and concerns about breastfeeding

BF-25

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

Rationale: Ongoing training for staff providing breastfeeding education is needed because infonnation abotit 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 of formula product names



office supplies such as cups, pens and note-pads free of formula product

names

Rationale: Use of materials with product names sends a mixed message to clients and staff and might unconsciously put up barriers to breastfeeding.

BF-26

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENTBF-4, cont'd

2. It is important to establish a positive attitude toward breastfeeding in WIC clinics.

Rationale: Health care workers should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, WIC staff should support her decision.

3. It is important that the local agency minimize the visibility of formula and bottlefeeding equipment. Consider:



storing supplies offormula out ofview ofparticipants



storing baby bottles and nipples out ofview of participants

Rationale: Formula and bottle-feeding equipment in clear view of participants may influence a mother's decision on infant feeding.

4. It is important that staff not accept formula from formula manufacturer representatives for personal use.

Rationale: Acceptance of formula for personal use may influence staff to endorse a particular product, either consciously or unconsciously. Acceptance of formula also conflicts with the program's breastfeeding promotion and support activities.

5. It is important that the local agency try to provide a supportive environment in which women feel comfortable breastfeeding their infants. Consider:



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 WIC staff.

6. It is important that the state agency assist local agencies in obtaining culturally sensitive and appropriate and translated breastfeeding education materials.

Rationale: The language and pictures in breastfeeding education materials should be relevant to the target population served by the program.

GUIDELINE#3

BF-27

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENTBF-4, cont'd

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

I. 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 of breastfeeding

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 ofFamily Physicians



American college ofNurse Midwives



American College of Obstetricians and Gynecologists



American Dietetic Association



American Hospital Association



American Nurses Association



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

BF-28

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd



Maternal and Child Health Directors



Medicaid Directors



National Association ofPediatric Nurse Associates and Practitioners

Rationale: Serving as an adjunct to health care is a vital component of the WIC Program. Therefore, it is important that the program's health-related policies be shared with appropriate health care programs and professional organization. such interaction encourages a strong cooperative working relationship with the health community to accomplish mutual goals.

3. It is important for local and state WIC agencies to participate in and support coordinated breastfeeding promotion and support activities such as:



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.

GUIDELINE #5

Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.

Suggestions for Implementation

BF-29

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

I. It is important that evaluation include measures of incidence and duration such as:



incorporation of data collection into current WIC systems



periodic sample surveys of program participants



Centers for Disease Control and Prevention surveillance systems



state surveillance systems



birth certificate information

Rationale: Since few data are available, data collection will help identify and direct further breastfeeding promotion efforts for this population. Assessment of successful strategies will help agencies measure progress toward meeting the health objectives for the nation.

2. Ifmore 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 combined 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 survey.

Rationale: Collecting data on breastfeeding attitudes, infant feeding practices and WIC-related promotion activities about breastfeeding assists state and local agencies design more effective breastfeeding promotion program components.

4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as:



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

BF-30

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

formula supplies



staff interaction with participants regarding the infant feeding decision and

breastfeeding support



local agency linkages with other community programs providing services to

breastfeeding women



staff training 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 of prenatal 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 methods of infant feeding is, in part, dependent on staff's ability and efforts to address women's needs and concerns throughout the prenatal period.

2. It is important to develop a mechanism to incorporate positive peer influence into the prenatal period, such as:



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

expenences

BF-31

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

Rationale: Positive peer influence bas been shown to be a factor in a woman's decision to breastfeed.

3. It is important to include the participant's family and fiiends in breastfeeding education and support sessions.

Rationale: Assistance and emotional support from family and friends are helpfulto a woman's initiation and continuation ofbreastfeeding.

4. It is important to encourage the mother to communicate her decision to breastfeed to appropriate hospital staff and physicians.

Rationale: To overcome potential barriers due to hospital and physician practices, women should be aware of the need to request the services that will facilitate successful breastfeeding, e.g., baby put to the breast soon after delivery.

5. It is important for the local WIC agency to coordinate prenatal breastfeeding education activities with primary care providers by:



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.

6. It is important that the local WIC agency know the breastfeeding practices of their community hospitals and primary health care providers.

Rationale: Local agency WIC staff should be part of the prenatal care team preparing women for their early breastfeeding experiences. Positive breastfeeding practices and policies facilitate successful breastfeeding.

GUIDELINE#7

Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless oftheir breastfeeding patterns.

BF-32

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

Suggestions for Implementation
I. It is important that eligible women who meet the definition of breastfeeding (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 of their breastfeeding pattern, need ongoing support so that they feel positive about their breastfeeding experience.
GUIDELINE #8
Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.
Suggestions for Implementation
I. It is important that the use of supplemental formula for breastfed infants be minimized.
Rationale: Support that encourages breastfeeding is more effective than offering more formula than the baby is currently using. Clear support which continues to build confidence includes praise and encouragement fo,; her current level of breastfeeding.
2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. If a food instrument must be distributed to enroll the infant,
BF-33

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

consider printing a positive breastfeeding message on the voucher.
Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.
3. It is important to encourage the issuance of vouchers for powdered formula to breastfeeding mothers who wish to supplement.
Rationale: Powdered formula can be prepared in as small a quantity as needed. However, the minimum amount of the concentrated fluid formula that can be prepared is 26 ounces. This amount must be used within 48 hours, which could encourage more supplementation than originally intended.
4. It is important that breastfeeding women receive information about the potential impact of formula on lactation and breastfeeding before formula is given.
Rationale: Breastfeeding mothers may not fully understand the impact formula supplementation has on breastmilk supply. This is especially important during the first few critical weeks when the milk supply is being established.
5. It is important that formula vouchers or samples be given only when specifically requested.
Rationale: Offering formula to a breastfeeding woman undermines her confidence that she can breastfeed successfully, particularly in the first few weeks. She also may find it difficult to refuse the free formula even though she had not planned to use it.
GUIDELINE#9
Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.
Suggestions for Implementation
1. It is important to develop a plan to provide women with access to locally available breastfeeding support programs, making sure support is available early in the
BF-34

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

postpartum period and throughout lactation to:



Include professional support, such as management of lactation 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 successfully breastfed an infant and who express a positive, enthusiastic viewpoint of breastfeeding.

2. It is important to provide or identify education and support for breastfeeding women in special situations. Consider:



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 impo~ant that postpartum contacts with breastfeeding women provide positive reinforcement for the continuation ofbreastfeeding. Consider:



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

BF-35

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-4, cont'd

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.

BF-36

GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-5

BREASTFEEDING RESOURCES RECOMMENDED BY THE OFFICE OF NUTRITION
PAMPHLETS (All of the 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)
+ BreastfeedingCanHelp 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) + Breastjeeding Doesn't Have To Be Embarrassing, Best Start, Inc. (#1027) + Breastfeeding Can Make Your Family Proud OfYou, 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 Information 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, lL, 1991.

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-5, cont'd

+ Breastfeeding Triage Tool, by Sandra Jolley
Breastfeeding Promotion Project, Seattle-King County Public Health, Seattle, WA, 1990.
+ Counseling the NursingMother: 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. al. Williams &Wilkins, Baltimore, MD, 1990.
+ Nursing Mother's Companion, by Kathleen Huggins
Harvard Common Press, Boston, MA, 1990.
+ Nutrition During Lactation, by the Institute of Medicine, National Academy of
Sciences National Academy Press, Washington, D.C., 1991
+ Nutrition Guidelinesfor Practice, by the Office ofNutrition
Office of Nutrition, Family Health Branch, Division of Public Health, Georgia Department ofHuman Resources, Atlanta, GA, 1995.
+ A Practical Guide to Breastfeeding, by Amy Kathryn Spangler
Amy Kathryn Spangler, Atlanta, GA, 1994.
+ Womanly Art ofBreastfeeding, by La Leche League International
La Leche League International, Franklin Park, IL.
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.

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-5, cont'd

+ Yes, You Can Breastjeed, (also available in Spanish), Texas Public Health.
Available from Metro Post, Attn: Ecko, 501 N. lli 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
+ Breastfeeding and Human 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 of telephone call
+ The Lactation Program
1719 E. 19th Avenue, Denver, CO, 80218 (303) 869-1881 Service Provided: Phone consultation with lactation consultants for difficult breastfeeding questions. Charge: None, beyond cost oftelephone call

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-6

ALLOWABLE AND UNALLOWABLE COSTS OF BREASTFEEDING AIDS USED FOR
THE PROMOTION AND SUPPORT OF BREASTFEEDING
The cost of breastfeeding 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 Progr~m cannot be purchased with NSA funds. Such items include, for example: topical creams, ointments, Vitamin E, other medicinals, foot stools, infant pillows or nursing blouses.

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-7

ISSUES TO CONSIDER WHEN PROVIDING BREAST PUMPS
WIC State agencies are currently making breast pumps available to WIC participants in a variety of ways, including:
a. giving away manual breast pumps or electric pump attachment kits;
b. selling manual breast pumps or electric pump attachment kits for a nominal charge;
c. loaning 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 AS.
Loaning Breast Pumps and Liability Issues
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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-7, cont'd

Manual breast pumps, attachment kits for electric pumps and small electric or battery operated pumps should not be reused, due to the possibility of cross-contamination from ' improper sterilization. The possible liability cost is high when compared to the cost for a one-person use ofa manual pump. In addition, the small electric/battery-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 directly purchase breast pumps for loan to participants may incur the financial liability of lost or damaged breast pumps. These pumps should be loaned in combination with some means to insure against loss or damage, such as:
a. establishing procedures to ensure that participants fully understand their rights and responsibilities when signing liability release forms;
b. developing an agreement between the Program and the participant which stipulates the participant's responsibility to reimburse the Program for the value of a lost or damaged pump;
c. monitoring through periodic visual inspection, frequent inventory counts and records, and telephone check-ins; or
d. limiting pump loans only to special circumstances, e.g., after a minimum duration 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 of the lost or damaged breast pump could easily exceed the value ofthe pump itself Building a relationship oftrust with WIC participants may minimize the risk ofparticipant not fulfilling the obligation to return the pump.
If it provides breast pumps, the WIC Program may also be liable for injury to a WIC participant resulting from improper breast pump use, even when there is a signed release of liability. This is true whether pumps are given, sold or loaned. All participants provided with breast pumps by the WIC Program must be instructed on proper pump use.

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENTBF-7, cont'd

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.
Referrals
A local agency may opt to refer WIC participants to providers who rent breast pumps directly; to participants at a fee, such as breast pump manufacturers, hospital pharmacies, and private lactation consultants. This option avoids the liability and financial issues for the Program. However, it is likely to pose a financial barrier to WIC participants. In the Georgia WIC Program, this does not meet the requirement for the provision of support to breastfeeding women.
Medicaid Reimbursement
The cost of manual pump purchase and electric pump rentals are generally not covered as a separate benefit under the Medicaid Program. However, in Georgia, the State Medicaid Program does cover the rental ofan 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 of the equipment. In these cases, the local agency staff should provide the necessary information and follow-up to the WIC participant.

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-8

STATUS CHANGE FROM PRENATAL TO BREASTFEEDING AND ASSIGNMENT OF PRIORITY TO BREASTFEEDING MOTHER AND INFANT

I. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification:

When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that ofPrenatal (P) to Breastfeeding (B) through an Update to the System. This should occur as soon as the local agency is made aware of the participant's change in status. A subsequent certification is not required in order to simply change the participant's status, as long as she is less than six (6) weeks postpartum. Note: This action does not exclude the participant from the required subsequent certification, in order to continue on the Program past the six weeks postpartum.

Listed below are examples of situations in which the simple status change from Prenatal to Breastfeeding might occur:



A woman calls the clinic to state she has delivered her infant and is

breastfeeding.



A parent of a newborn breastfeeding infant comes to the clinic to

enroll the infant in the Program.



A local agency does in-hospital certification of infants only.



A breastfeeding peer counselor notifies the clinic that a participant has

delivered her infant and is breastfeeding.

Follow the steps listed below to change the Status of a prenatal women, prior to her subsequent certification (Source: ATVS User's Manual):

A. Change TYPE from P to B, since subsequent certification may not take place until 6 weeks postpartum.

B. Change/add the following: DELIVERY DATE, PREGNANCY OUTCOME, and NUMBER OF WEEKS BREASTFED.

C. Change the following if determined to be appropriate (these are optional changes):

1. PRIORITY. A breastfeeding woman's priority can be upgraded if one
or more breastfeeding risk factors are identified. The risk facto(s) must be documented in the participant's health record. See II. Assignment of Priority to Breastfeeding Dyad, below.

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-8, cont'd

2. FOOD PACKAGE. Ifthe Competent Professional Authority (CPA) determines that a food package change is needed, assign a new food package. Participants who are exclusively breastfeeding (receiving no infant formula through WIC) should be assigned Food Package 408. Ifthis participant has already picked up the current month's prenatal vouchers, you may print a single "001" voucher for her. This voucher includes the additional beans/peas or peanut butter, carrots and juice which are part ofthe 408 food package.
ll. Assignment of Priority to Breastfeeding Dyad
When a participant's status is changed from Prenatal (P) to Breastfeeding (B), prior to her postpartum certification, it may not be possible to assign the same priority to both mother and infant at this time. Please follow these steps in assigning the priorities:
A When a participant's status is changed from Prenatal (P) to Breastfeeding (B) through a System Update, her priority may be upgraded if there is appropriate documentation. This is optional, however, and she can maintain her Prenatal priority until the subsequent certification.
B. When a breastfeeding infant is certified for, and enrolled in, the WIC Program prior to its mother being subsequently certified, the infant may be assigned one ofthe following priorities:
I. Ifthe infant has a risk factor of its own that would result in it's being a priority I, the infant must be assigned a Priority I.
2. If the infant has no nutritional risk factor of its own except risk "W" (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority ll. It may be helpful to "flag" the infant's name/record through an internal tracking system (tickler card, computer, voucher register, etc.) to alert staff to the need to reevaluate the infant's priority at the mother's postpartum certification.
3. Ifthe infant's mother was assigned a Priority I based on documented postpartum breastfeeding risk factors, assign a Priority I to the iB.fant.
C. When the mother of a breastfeeding infant is certified at a later time than the infant, one ofthe following actions must be taken:
I. If the mother is no longer breastfeeding, she must be assessed as a
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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-8, cont'd

non-breastfeeding postpartum woman (status is changed from P toN), and she must be assigned the appropriate priority based on the assessment. Her infant retains the priority assigned at its enrollment.
2. If the mother is still breastfeeding, she must be assessed as a breastfeeding woman (status is changed from P to B). The highest priority ofeither the mother or her infant(s) must be assigned to both mother and infant(s). This priority and the supportive risk criteria must be documented in the health record of both the mother and her infant(s).

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GA WIC PROCEDURES MANUAL FY '97

ATTACHM:ENT BF-9

KEY FOR ENTERING WEEKS BREASTFED

The number ofweeks 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 of time breastfed must be entered in weeks (two-digit). When the answer to the question "how long have you breastfed this baby/child?" or "how long has this baby/ child been breastfed?" is given in days or months, use the following key to determine appropriate codes:

I. Codes to Enter When Breastfeeding is Given in Days

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.

IT. Codes to Enter When Breastfeeding is Given in Months

If the length of breastfeeding is given in months, simply multiply by four (4) to calculate the number of weeks 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.

Sources:

Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division

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GA WIC PROCEDURES MANUAL FY '97

ATTACHMENT BF-9, cont'd

of Nutrition, Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department ofHealth and Human Services, Public Health Service. November 1989
Georgia WIC User Manual, 1994.

BF-48

TABLE OF CONTENTS

Page

I.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-1

A. Purpose ................................................ DP-1

B. Scope ................................................. DP-1

II.

Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-2

IV.

Concept of Operations .......................................... DP-3

A. General ................................................ DP-3

B. Organization (state and local agency responsibilities) ............ DP-3

C. Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-4

V.

Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-5

A. Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-5

B. Issuance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-5

C. Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-7

D. Nutrition Education Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-7

VI.

Resource Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-7

A. Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-7

B. Infant Formula .......................................... DP-8

C. Food Instruments ........................................ DP-8

D. Transportation .......................................... 'DP-8

Attachments:

DP-1 Staff Availability Following Disaster

DP-9

DP-2 Disaster Employee Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DP-1 0 DP-3 Disaster Daily Work Activity Log ...................................... DP-11 DP-4 American Red Cross Emergency Numbers ............................... DP-12

GA WIC PROCEDURES MANUAL FY'97

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 WIC Agency in the event of a disaster or emergency creating a disruption in service delivery at a local agency. WIC local agency staffwill 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 DHR Emergency Plan (or Public Health).

The Georgia WIC Program, during some instances briefly suspend WIC operations and rely entirely on other disaster feeding operation (i.e., American Red Cross, Salvation Army, churches etc.) until it is feasible to operate a direct distribution system or until retail distribution is available.

In the event of suspension of the WIC Program during this period, the State WIC Office will make copies available ofthe Food Pantries and Food Assistance Program Booklet to the appropriate relief organization and relief shelters. The Food Pantries and Food Assistance Program Booklet is updated yearly in November and will be sent to organizations by January of each year.

DP-1

GA WIC PROCEDURES MANUAL FY'97

The State/local agency must also make an initial and on-going assessment as to feasibility ofdistributing ready-to-feed infant formula. Every effort will be made to determine the food and formula acquisition and distribution (in accordance with) the American Red Cross and other organizations. The State/local agencies will also assess situations. (See III DP-2) The decision to use ready-to-feed infant formula will be made on a day by day assessment of the situation and type of disaster.

The Emergency numbers for contacting the American Red Cross are also attached to this Plan (See Attachment DP-4). The contact person as well as a fax number is also available in (Attachment DP-4).

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 ofan 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.

ASSESSING IMPACT OF DISASTER

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?

5. Are electric, water, communication and transportation services disrupted?

6. How long could services be disrupted?

7. What alternative to current policies and procedures must be made?

DP-2

GA WIC PROCEDURES MANUAL FY'97

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 current phone listings for the Regional Food Nutrition Services Offices, County Public Health Unit Disaster Coordinators, State Health Office Disaster Coordinators, statewide and local chapters ofthe 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 arrivaVreceipt 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 disaster 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 WIC 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 oftracking and reconciling costs relating to the disaster. The Manager of the Quality Assurance Unit will have responsibilities related to insure documentation for the use of vouchers. Staff would be assigned to serve at the location according to a schedule. The Manager of the Vendor Unit will have responsibilities ofproviding 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 information. 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.

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GA WIC PROCEDURES MANUAL FY'97
State and Local Agencies
~
The state and local agencies will coordinate efforts to obtain the appropriate type and quantity ofstaffto assist the local agency in need. Staffmay 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.
Foilowing 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 situation and availability for duty assignments. If none of the local agency's immediate supervisors can be reached, local agency staffcan call the State WIC Office at 1-800228-9173 to report their status and phone number where they can be reached. Attachment DP-1 is a form 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 DP-2. 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 DP-3. 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.
C. Notification
Lines ofcommunication 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.
DP-4

GA WIC PROCEDURES MANUAL FY'97

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 may include, but is not limited to, moving contents and equipment files, acquiring security services, securing buildings, or other necessary activities.

The records and invoices ofany 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 ru;sisting in locating potential points for direct distribution ofinfant 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 ofavailable facilities, records or food instrument supplies, the state agency will coordinate efforts with the local agency to ensure that a minimal supply of food or food instruments are available for participants if such action is necessary. Securing formula for WIC infants effected by the disaster is the top priority of any state agency disaster relief plan. Ready-to-feed formula may be necessary ifthe area where water supply is contaminated and/or electrical power is disrupted. State government officials, state and local agencies will collaborate daily (or as needed) to determine the most appropriate food distribution method. In the event that readyto-feed infant formula is required, efforts will be made to order appropriate-amounts (along with disposable nipples and bottles). As soon as the disaster area returns to normal or ifanother agency accepts responsibility for formula, distribution for readyto-feed formula will be discontinued. Adult 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

DP-5

GA WIC PROCEDURES MANUAL FY'97
maintain a list of retail grocery stores that remain in operation follo.vving the disaster, their operating hours, and their available stock ofWIC 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, and Disaster 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 theclosure ofmany 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 offood 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 may elect to take other appropriate measures to supply the local agency with infant formula, 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.
3. Special Formula/Hospital Based Form'.lla: The state agency and local agency will estimate the quantity of special formula and hospital based formula needed to sustain services until normal 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 formula 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.
DP-6

GA WIC PROCEDURES MANUAL FY'97
5. Food Package: The WIC Competent Professional Authority (CPA) dete:pnines the type offood 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 ofthe 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 ofthe 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 WIC Office. Special provisions to extend certification periods when clinic does not have adequate lab facilities will be taken under consideration.

D. Nutrition Education Contacts

Nutrition education may be provided in group or individual setting during certification 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 REQUIREMENTS

A. Staff

I. Analysis of the need caused by the disaster and monitoring and

DP-7

GA WIC PROCEDURES MANUAL FY'97 control of the response.
2. Coordination ofWIC 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 fmancial staff, monitoring and tracking all costs related to the disaster recovery.
B. Infant Formula *
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 (i.e., helicopters, airplanes, over land all terrain trucks.)
C. Food Instruments 1. Obtaining supply of blank food instruments for state office remote printing. 2. Printing and shipment ofpre-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.
DP-8

GA WIC PROCEDURES MANUAL FY'97

Attachment DP-1

STAFF AVAILABILITY FOLLOWING DISASTER

DATE & Til\tfE. CALL
RECEIVED

DISTRICT/UNIT CLINIC

I
I

j
I

NAl\tfE

PHONE

DATE&TIME CAN RETURN TO
WORK

COMMENTS

DP-9

GA WIC PROCEDURES MANUAL FY'97 DISASTER EMPLOYEE LOG

Attachment DP-2

PAGE

OF

forPAYPERIOD

to------

(beginning)

(ending)

DISASTER IDENTIFICATION/(CLINIC #): - - - - - - - - - - - - - - -

DISTRICT:

OFFICE N A M E : - - - - - - - - - - - - - - -

CONTACT NAME:-----------------------------------

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
DP-10

GA WIC PROCEDURES MANUAL FY'97

Attachment DP-3

DATE:

DISASTER DAILY WORK ACTIVITY LOG

I

I

PAGE OF

NAME: DISTRICT:

OFFICE:

SSN:

AM

AM

NEW ACTIVITY TIME: -~- PM to-~- PM

BLDG: _ _ OTHER: _ _

ACTIVITY LOCATION: Activity D e s c r i p t i o n : - - - - - - - - - - - - - - - - - - - - - - - - -

(USE REVERSE SIDE IF NECESSARY)

AM

AM

NEW ACTIVITY TIME: -~- PM to-~- PM

BLDG: _ _ OTHER: _ _

ACTIVITYLOCATION: - - - - - - - - - - - - - - - - - - - - - - - Activity Description:-------------------------

(USE REVERSE SIDE IF NECESSARY)

AM

AM

NEW ACTIVITY TIME: -~- PM to --=---- PM

BLDG: _ _ OTHER: _ _

ACTIVITYLOCATION: - - - - - - - - - - - - - - - - - - - - - - - - - Activity Description:------------------------------

(USE REVERSE SIDE IF NECESSARY)
SIGNATURE: -----------DATE: ---------NOTE: MUST ATTACH TO DISASTER EMPLOYEE LOG
RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS

DP-11

GA WIC PROCEDURES MANUAL FY'97

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 ClusterV Coverage: Sumter

Joan Mason P.O.Box214 Americus, GA 31709 {912) 924-2026 Fax:{912) 931-0811

Augusta Clustern 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 Clustervn Coverage: Bartow

Beth Kennedy I05 North Bartow Street Cartersville, GA 30120 {404) 382-0981 Fax:{404) 606-1600

Bulloch County Cluster ill Coverage: Bulloch, Candler, Emanuel

Vacant P.O.Box843 Statesboro, GA 30458 {912) 767-4468

Fort Gordon Dwight D. Eisenhower Army Medical Center

Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 {706) 791-3169/6341 After Hours:{706) 791-4517 Fax:{706) 790-4822

Fort McPherson

Kathy Staten Bldg. 536 Ft McPherson, Ga 30330 {404) 753-8315

Fort Stewart Wino Army Community
Hospital

Lynn Dowling Bldg. 8401 P.O. Box 3280 Fort Stewart, Ga 31314 {912) 767-8857/2197 After Hours:{9!2) 767-2197/8666 Fax:{9!2) 368-6353

Hunter Army Airfield

Mark Stall Building40! Hunter Army Airfield, GA 31409 {912) 352-5410 After Hours:{912)65!-531 0

Marine Corp Supply School
Covered by: Albany Chapter

Moody Air Force Base

John Lukens 5124 Austin Ellipse Moody AFB, GA 31699 {912) 244-3570 Fax:{912) 333-3114

Nanl Air Station Albany

Attaclunent DP-4

Georgia Low Country Cluster ill Coverage: Liberty, Long, Tattnalli, Wayne

Kenny Murphy P.O.Box242 Hinesville, GA 31313 {912) 876-3975

Glynn County Clusterm Coverage: Appling, Glynn, Mcintosh

Beth VanDerbeck P.O. Box 1436 Brunswick, GA 31521 {912) 265-6467/1695 Fax:{9!2) 261-1443

Gordon County Cluster VII Coverage: Gordon

Mary Thomas P.O. Box342 Calhoun, GA 30703-0342 {706) 629-4510

Griffin Clustervm Coverage: Spalding

Brenda Hoard I00 South Hill Street Griffin, Ga 30244 {404) 227-3145

Houston-Middle Georgia Cluster VI Coverage: Bleck!ey, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox

Sam Register 346 Corder
Warner Robbins, GA 31088 {912) 923-6332 Fax:{912) 922-8858

Metropolitan Atlanta Clustervm Coverage: Fulton, DeKalb, Gwinnett, Cobb, Cherokee, Paulding, Fayette, Butts, Henry, Clayton, Douglas, Rockdale

Martha W. Ferguson 1955 Monroe Drive, N.E. Atlanta, Georgia 30324 {404) 881-9800 Fax: {404) 874-2993

Murray County Cluster VII Coverage: Murray

Annette Patton P.O. Box 1301 Chatsworth, Ga 30705 (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) 282-1722 (in GA)

Rome-Floyd County Cluster VII Coverage: Chattooga, Dade, Floyd, Polk

Jean Lambert 311 Turner McCall Blvd. Suite A Rome, GA 31065-2733 (706) 291-6648 Fax:(706) 235-2842

Savannah Chapter Cluster ill Coverage: Bryan, Chatham, Effingham

Angela Viney 422 Habersham Street Savannah, GA 31401 (912) 651-5300/5310/5385 Fax:(912) 651-5329

Southeast Georgia Cluster ill Coverage: Atkinson, Bacon, Brantley, Clinch, Coffee, Jeff Davis, Pierce, Telfair, Ware

Ossie Andrews 809 Isabella Street Waycross, Georgia 31501 (912) 283-7846/4639

Thomas County Cluster IV Coverage: Decatur, Grady, Seminole, Thomas

Gardiner Hasty P.O. Box 1135 Thomasville, Georgia (912) 226-2181

31799-1135

DP-12

GA WIC PROCEDURES MANUAL FY'97

Tift County Clusterrv Coverage: Ben Hill, Irwin, Tift, Turner, Worth

Maxine Franks P.O. Drawer 70770 Tifton, Georgia 3!793 (912) 382-3133

Toombs County Ciusterm Coverage: Montgomery, Toombs, Treutlen, Wheeler

Stan Bazemore P.O.Box49 Lyons, Georgia 30436 (912) 526-3150

Troup County ClusterV Coverage: Troup

Barbara Hudson 411 South Greenwood St Suite#B LaGrange, Georgia 30240 (706) 884-5818 Fax: (706) 882-4364

Upson County Cluster VI Coverage: Pike, Upson

Jeanne Hinson 310 North Church Street Thomaston, Georgia 30286 (706) 647-3023

Valdosta Clusterrv Coverage: Berrien, Brooks, Echols

Stephen Coyne 707 North Patterson Street Valdosta, Georgia 3160 I (912) 242-7404 Fax: (912) 242-1553

Walker County Cluster VII Coverage: Walker

Jerry Lipps P.O.Box372 Lafayette, Georgia 30728 (706) 638-2546

Naval Air Station Atlanta Covered by: Fort McPherson

Ranger School Covered by: Ft Benning

Robins Air Force Basel Hospital

RobinsAFB

Chris Miller Family Support Center 825 9th Street Suite #109 Robins AFB, GA 31098 (912) 926-5493 After Hours: (912) 923-6332

Attachment DP-4

Walton County Cluster II Coverage: Walton

Don Shedd 2499 Pannell Road, S.E. Monroe, GA 30655-9611 (404) 267-3534 Fax: (404) 207-4338

West Central Georgia ClusterV Coverage: Calhoun, Chattahoochee, Harris, Marion, Meriwether, Muscogee, Putnam, Quitman, Stewart, Talbot, Webster

Jean Kent 3940 Rosemont Drive Columbus, Georgia 31904 (706) 323-5614 Fax: (706) 322-2495

West \ieorgia Cluster VII Coverage: Carroll, Clay, Harralson, Randolph, Schley

Marianne Chance 40 I Bradley Street Carrollton, Georgia 30117 (404) 832-6112

Wilkes County Cluster II Coverage Wilkes

Sniggy Eskew . P.O.Box774 Washington, GA 30673 (706) 678-4650 Fax: (706) 678-3752

Fort Gillem Covered by: Fort McPherson

Dobbins Air Force Base Covered by: Fort McPherson

Fort Benning/Martin Army Hospital

Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706) 545-5!94 Fax: (706) 545-5118

DP-13

FFY '97 Georgia WIC Program Procedures Manual Glossary

Adjunctive Eligibility -Automatic income eligibility for WIC applicants.
Administrative and Program Service Costs - Direct and indirect costs, exclusive of food costs, which State and local agencies determine to be necessary to support Program operations.
Affirmative Action Plan - Portion of the State Plan which describes how the Program will be initiated and expanded within the State's jurisdiction.
Agricultural Occupation - Employment related to the production, growth, and harvesting of commodities grown in or on land, or an adjunct to a part of a commodity grown in or on land.
Allocation of Funds - The allocation of funds is based on a methodology that includes an analysis of the 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 Allocation Advisory Committee determines which types will be served. The allocation of administrative funds is based on an average cost per participant and is distributed to the local agencies after state administrative costs have been deducted.
Alphabetic Client Masterfile- An enrollment report which lists selected participant information for all active participants.
ARMIS - Automated Reports Management Information System -Provides quick and accurate retrieval ofWIC data at the State, DIU, and Clinic level without resorting to the time consuming effort ofviewing paper or microfiche reports.
Automated Termination Action - The system which automatically terminates a participant when a child reaches his/her fifth birthday, a non-breast-feeding woman at 6 months, a breast-feeding woman at 12 months from delivery, failure to pickup vouchers for 2 full consecutive months, transfer out of clinic or district/unit, terminated from waiting list, pregnant
woman at EDC + 75 days, or overdue for certification.
Automated TADNoucher System (ATVS)- Computer system developed by the State WIC Office to create vouchers and prepare automated turnaround documents (TADs). The vouchers and TADs are submitted to the ADP contractor via modem or diskette.
Automatic Update of Infant to Child - The system automatically updates an infant to a child when the infant reaches his/her first birthday.
Batch Control Form - A 3 ply form which is completed for each transmitted batch ofTADs sent to Viking. This form is ordered from DOAS Central Supply through the State WIC Office. A completed form contains the date the batch was

assembled, and a four digit sequence number assigned to this batch (can not be duplicated within the same date). The date and the sequence number combined is the Batch control number. This number is printed on the computer printed TAD. The district/unit code, clinic code, the number of TADs or Vouchers in the batch (do not mix TADs and vouchers in a batch), the person who prepares the batch should sign and date the Batch Control form upon completion. The top copy ofthe form goes to the ADP contractor. The second and third copies are retained by the clinic.
Blank Manual Vouchers - Vouchers that require manual entry of certain information by the clinic prior to issuance. It is commonly used for issuance when replacing only a part of a participant's computer generated voucher package, to a newly certified participant or transferring participants when a standard manual voucher package is inappropriate, or to supplement the preprinted manual voucher food package.
Breastfeeding Women - Women up to one year postpartum who are breastfeeding their infants.
Budget - An itemized summary of probable expenditures and income for a given period.
Calendar Year- The period oftime between January 1st and December 31st.
Categorical Termination - Child who has reached his/her fifth birthday, Postpartum non-breast-feeding woman 6 months after delivery, Postpartum breast-feeding woman 12 months after delivery.
Categorical Eligibility - Woman, Infant or Child who meet the definitions of pregnant women, breastfeeding women, postpartum women, or infants or children.
Certification - The implementation of criteria and procedures to assess and document each applicant's eligibility for the Program.
Children - Child who have had their first birthday but have not yet attained their fifth birthday.
Clinic - A facility where applicants are certified.
Closeout Month- The third month (sixty days) after vouchers were issued.
Closeout Reconciliation Report- Report generated at the clinic level to give the final disposition of all computer printed vouchers.
Collections - Repayment of WIC funds that were received fraudulently and must be made by cashiers check or money order.

1

Communal Feeding- Group meals or food supplies.
Competent Professional Authority- An individual on the staff ofthe local agency authorized to determine nutritional risk and prescribe supplemental foods. The following persons are the only persons the State agency may authorize to serve as a competent professional authority: Physicians, nutritionists, (Bachelor's or Master's Degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition or Home Economics with emphasis in Nutrition), dietitians, registered nurses, physician's assistants (certified by the National Committee on Certification of Physician's Assistants or certified by the State medical certifying authority), or State or local medically trained health officials. This definition also applies to an individual who is not on the staff ofthe local agency but who is qualified to provide data upon which nutritional risk determinations are made by a competent professional authority on the staff of the local agency.
Computer Generated Vouchers- These vouchers contain a specific food package, individually tailored for each participants nutritional needs. These vouchers 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.
Computer Printed Voucher Register- A listing ofparticipants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers.
Confidentiality- The WIC Program may give the participants certification information to other Health Public Assistance programs to see if the participant is eligible for their services. These agencies may contact the applicant, but they may not give any information to anyone else without obtaining the participants permission.
Cost Containment Measure - A competitive bidding, rebate or direct distribution implemented by a State agency as described in its approved State Plan of operation and administration.
CSFP - The Commodity Supplemental Food Program administered by USDA.
Cumulative Unmatched Redemption - Identifies redeemed manual vouchers, which have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report. The vouchers should be reconciled or a manual reconciliation should be done, depending on how much time has elapsed since the voucher was redeemed.
CUR Part 1- Cumulative Unmatched Redemptions which have not matched to an issuance record.
CUR Part 2 - Cumulative Unmatched Redemptions which have not matched to a valid certification record.
Delivery Date - Indicates the date of actual delivery of an infant

(or the date the pregnancy ended) for a postpartum woman
Disability - A physical incapacitated or disabling condition which prevents or restricts normal accessibility or activity included are visual and hearing impaired individuals.
Disqualification - The act of ending the program participation ofa participant, authorized food vendor, or authorized State or local agency, whether as a punitive sanction or for administrative reasons.
Disqualified Vendors - Vendors that are found to be in violation of program policies and regulations through compliance investigation. Vendors will be assessed sanction points for violations occurring in each investigation visit.
Donations - WIC foods and other food items purchased as a result ofthe compliance investigations. These items are donated to non-profit organizations within the city (ies) where the purchases are made by the investigator.
Dual Participation Report - This report specifies possible dual participants in alphabetic sequence, which must be investigated by the local agency and submitted to the State WIC Office.
Dual Participation - WIC participants who receive benefits twice in the same clinic, or from more than one clinic.
EDC (Estimated Date of Confinement) - Indicates the date of expected delivery for a pregnant woman.
Education Level - Indicates the highest level or grade completed, for women participants only.
Equipment Inventory - A detailed listing of all property purchased with WIC funds and valued at a minimum of $100.00.
Fair Hearings - Procedures under which a person or his/her guardian will be guaranteed the right to appeal a decision or action by the State or local agency which results in the individuals denial of participation, suspension, or termination from the program.
Family- A group ofrelated or non-related 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.
Family Size - Identifies the total number of individuals in a household.
Fiscal Year - The WIC Program operates under the constraints of both the federal fiscal year (October 1 through September 30) and the state fiscal year (July 1 through June 30).
FNS - The Food and Nutrition Service of the United States Department of Agriculture.
Food Delivery System - The method used by State and local

2

agencies to provide supplemental foods to participants.

Food Costs - The costs of supplemental foods.

Food Instrument - A voucher, check, coupon or other document which is used by a participant to obtain supplemental foods.

Grant Award (Formula Grant/Grant Allocation) - Total (food and admin) dollars allocated to the State for the federal fiscal year based on funding formula.

Health Services - Ongoing, routine pediatric and obstetric care (such as infant and child care and prenatal and postpartum examinations) or referral for treatment.

Height - The vertical length (depending on the age) of a participant to the nearest eighth inch.

Hematocrit- Medical criteria required to assess nutritional risk.

Hemoglobin - Medical criteria required to assess nutritional risk.

Homeless Individual -A woman, infant or child who lacks a fixed and regular night time residence; or whose primary night time residence is: A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodation; an institution that provides a temporary residence for individuals intended to be institutionalized; a temporary accommodation in the residence of another individual; or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

Homeless -A woman, infant or child who does not have regular fixed night time residence, or resides in a temporary public or private shelter.

Homeless Facility - A supervised publicly or privately operated shelter (including a welfare hotel or congregate shelter) designed to provide temporary living accommodations; a facility that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for, or normally used as, a regular sleeping accommodation for human beings.

Incident/Complaint Form

Form #3772 titled

Incident/Complaint Form. This form is used to document

complaints from participants, vendors, USDA, etc.

Income - Gross cash income before deductions for income taxes, employee's social security taxes, insurance premiums, bonds, etc.

Infant Mid-Certification Nutrition Assessment - This JSsessment to be completed between five and seven months of age for an infant. The infants weight, height, hemoglobin or hematocrit, diet, nutritional risk, and food package needs are

evaluated during this assessment. This assessment ensures accessibility to quality health care services.

Initial Contact Date- The date an applicant first visits the WIC clinic during office hours and requests WIC benefits, orally or in writing.

Institution - Any residential facility designed to provide meals and living accommodations for individuals intended to be institutionalized but excludes private residences or homeless facilities.

Institutionalize - To reside in, by choice or otherwise, an established residential facility that provides accommodations and meals.

Issue Month - The month in which vouchers were issued.

Local Agency- (a) A public or private, nonprofit health or human service agency which provides health services, either directly or through contract.

Logger - An individual whose primary employment is the harvesting of trees seasonally; and for such work the person establishes temporary residence.

Manual Voucher Inventory Log - Documentation that vouchers are inventoried on a weekly and monthly basis.

Medical Care Start Date - Indicates which month of the pregnancy the woman began receiving prenatal care

Members of Populations - Persons with a common special need who do not necessarily reside in a specific geographic area, such as off-reservation Indians or migrant farm workers and their families.

MIER ( Monthly Income and Expense Report) - An itemized

summary of all WIC expenditures reported monthly by each

Local Agency.



Migrant Farm workers - An individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.

Migrant - A seasonal farm or agricultural worker or family member who travels from place to place for the purpose ofwork and such work requires the establishment of temporary residence.

Native American - The original inhabitants of America; an

American Indian.

'

Non-Participation- Participants in a valid certification period who do not pick up or redeem vouchers (manual or computer) are counted as a non participant.

Non-Breast-feeding - Postpartum woman who is not breast-feeding an infant.

3

Non-English Speaking- Individual whose primary language is not English or speaks little English.
Nonprofit Agency- A private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.
Numeric Client Masterfile - An enrollment report, which list all active participants. This report is a cross reference for the Alphabetic Client Masterfile. It provides the client names by ID number.
Nutrition Education - Individual or group education sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health.
Nutritional Assessment- Contains medical data obtained and evaluated by a CPA, which determines a participant's nutritional risk.
Nutritional Risk - Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; other documented nutritionally related medical conditions; dietary deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.
OIG- The USDA Office ofthe Inspector General.
Participant Hardship - If disqualifying a vendor causes hardship to WIC participants, the vendor shall be granted a probationary period. A hardship case is granted if 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.
Participation - The sum of the number of persons who have received supplemental foods or food instruments during the reporting period and the number of infants breast-fed by participant breastfeeding women (and recelVlng no supplemental foods or food instruments) during the reporting period.
Post Vendor Training Evaluation- A test pertaining to WIC vendor requirements given to all vendors when attending the initial and annual vendor training.
Postpartum Women - Women up to six months after termination of pregnancy.
Poverty Income Guidelines - The poverty income guidelines prescribed by the Department of Health and Human Services. These guidelines are adjusted annually by the Department of Health and Human Services, with each annual adjustment effective July 1 of each year.
Pregnancy Outcome - The results of the just ended pregnancy

for the postpartum woman participant.

Pregnant Women- Women determined to have one or more embryos or fetuses in utero.

Prenatal Women- Pregnant female between the ages of10 and 55 years.

Prenatal Weight- Prenatal woman's weight prior to delivery.

Priority I- Pregnant women, breast-feeding women, and infants at nutritional need determined by measuring height/weight, taking a blood test and medical history.

Priority II (Breast-feeding women) -Women who do not qualify under priority I, but are breast-feeding Priority II infants.

Priority II (Infants) -Infants up to six months of age born to women who were WIC Program participants during their pregnancy, or infants born to women who were not WIC Program participants during their pregnancy but had a nutritional need.

Priority III (Postpartum) - Postpartum teenagers who are not breast-feeding.

Priority III (Children) - Children with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.

Priority IV- Pregnant women, breast-feeding women, and infants with a nutritional need because of poor diet or homeless/migrancy status.

Priority V - Children with a nutritional need because of poor diet or homeless/migrancy status.

Priority VI - Postpartum, non-breast-feeding women with a nutritional need, or homeless/migrancy status and homeless/migrant postpartum non-breast-feeding teenagers.

Processing Standards - Period from the time an applicant requests WIC services in person to the time he/she receives services.

Program - The Special Supplemental Food Program for Women, Infants and Children (WIC) authorized by section 17 of the Child Nutrition Act of 1966, as amended.

Prorate -The partial issuance of vouchers. The most common cause for the partial issuance of vouchers is missed appointments for voucher pick up. The number of vouchers withheld depends on the number of days the participants are late picking up their vouchers.

Proxy

Responsible person whom the

participant/parent/guardian/caretaker chooses to act on his/her

behalf. A participant may designate up to 2 persons to act as

proxy. The proxies must sign the space on the participant's

WIC ID card. An authorized proxy may pick up or redeem

4

vouchers and may bring the child in for subsequent certifications, in restricted situations.
Racial Group of Participant- l=White, 2=Black, 3=Hispanic, 4=Native American, and 5=Asian, Pacific Islands
Reason for Certification- A participant's nutritional need for the WIC Program, based on the medical/nutritional data collected at the time of certification
Redemption- The exchange ofWIC vouchers for supplemental foods at participating grocery stores. Only authorized foods (listed on the face ofthe voucher) may be purchased.
Refugee - Someone who flees his or her native country due to persecution or well-founded fear of persecution because of race, religion, nationality, political opinion, or membership.
Residency- Determi!Jed by using the applicant's self-declared address.
Residual Funds - Funds remaining available for allocation to State agencies after every State agency has received the amount allocable to it as stability finds.
Return Voucher Payment Form -Form #3760 titled Return Voucher Payment Log. Vendors use this form used by Vendor when sending vouchers, that have been returned to them from the bank, to the State WIC Office for payment.
Sanction Point System - Form #3796 titled Sanction Point System. A system of point values that is used to sanction vendors for violations of program policy and/or regulations. 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.
Sanction Points - Each violation has a set point value. When violations occur points are given based on the severity of the violation. Form #3796 titled Sanction Point System lists all of the offenses and their point value.
Seasonal Farmworker - A worker employed in agriculture occupation whose residence is not temporary for the purpose of such work.
Secretary - The Secretary of Agriculture.
SFPD -The Supplemental Food Programs Division ofthe Food and Nutrition Service of the United States Department of Agriculture.
Special Population -An Individual or a group of individuals with common needs who require special assistance or service to access and participate in WIC related services.
Special Formula - Formula that is not the standard contract formula. This formula is approved when a written prescription from a medical doctor with the diagnosis included is given to the participant.

Stability Funds- Funds allocated to any State agency for the purpose ofmaintaining its preceding year's Program operating level.
Standard Formula- A particular type of formula provided by the State. All infants participating in the Georgia WIC Program will be provided with vouchers for the formula the program is under contract to use.
State - Any of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Marinas Islands and the Trust Territory ofthe Pacific Islands.
State Agency - The health department or comparable agency of each State; an Indian tribe, band or group recognized by the Department of the Interior.
State Plan- A plan of Program operation and administration that describes the manner in which the State agency intends to implement and operate all aspects of Program administration within its jurisdiction.
Supplemental Foods -Those WIC foods containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants and children.
Temporary Relocation - The establishment of a temporary residence for individuals whose primary place of residence is lost as the result of disaster, or other privation.
Temporary Accommodation - A public or private shelter or the residence of another person used for temporary living and sleeping accommodation.
Time Study - A process of data collection and compilation designed to sample the activities of: *Non-WIC paid personnel if local agencies are using the time study to justify reimbursement ofpersonnel costs. *All staffwhose salaries are paid in part or in full by WIC or whose time is used to offset shared costs.
Training Information Form - Form #3758 titled Vendor Training Information Form. This form is used to list owners/store managers that did not attend the annual training and whose Vendor Agreement was not renewed.
Transfers, Into - This transaction is used to transfer a participant already assigned an ID number on the computer system from one Georgia WIC Clinic to another. The transaction code is (X).
Turnaround Documents (fADs), Blank- A TAD which only has the Clinic Code field preprinted on it. This TAD is used for enrolling any additional family members onto the computer system through the use of either an Initial Certification, Waiting List, or Out ofState Transfer input transaction. This TAD may also be used to complete an in-state transfer or any time a Computer Printed TAD is not available.

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Turnaround Documents (TADs), Prenumbered- A TAD has the Clinic Code field and the complete WIC ID Number field (with participant code 1) preprinted on it. The remainder of the form is blank. This TAD is used for enrolling the first member ofa family onto the computer system through the use ofeither an Initial Certification, Waiting List, or Out of State Transfer input transaction.
Update/Infant Assessment - This transaction is used to change, correot, or update information for a participant already assigned an ID number on the computer system. This transaction is also used to enter the mid-certification nutritional assessment information for an infant already on the computer system. The transaction code is (U).
USDA - The United States Department of Agriculture.
VAMP - Vendor Activity Monitoring Profile. A report used to identifY high risk vendors.
Vendor Sanctions- When a WIC vendor is found to be in violation ofprogram policy and/or regulations, that vendor will be assessed sanction points according to the severity of the violation. When a vendor accumulates twenty-five (25) or more sanction points, the store shall be disqualified from the WIC Program.
Vendor Monitoring - Local agencies must perform on site visits to all WIC vendors at least once every two (2) Federal Fiscal years.
Vendor Input/Registration Document- A form that is used to add a new vendor to the active vendor list. Also used to make name, address and telephone number changes. Corrections in vendor type and county codes, and vendor termination/disqualification are submitted on this form. It does not have a form number and the title of the form is Vendor Registration.
Vendor Materials- A list of all the vendor forms and booklets that are available.
Vendor Training Checklist - Form #3757 titled Vendor Training Checklist. This form is used to indicate subjects covered during training.
Vendor Sanctions -When a WIC vendor is found to be in violation ofprogram policy and/or regulations, that vendor will be assessed sanction points according to the severity and nature ofthe violation. When a vendor accumulates twenty-five (25) or more sanction points, the store shall be disqualified from the WIC Program. Form #3796 titled Sanction Point System lists all of the offenses and their point value.
Vendor Compliance Investigation - Vendors that have been identified as "High Risk" by the State WIC Office through the use of VAMP, complaints, or request for investigation forms received from the districts.
Vendor Profile Report - A report that gives data on the

disposition ofvouchers cashed by each vendor. Also provides high risk indicators.
Vendor Training Checklist - Form #3757 titled Vendor Training Checklist. Form is used to indicate subjects covered during training.
Vendor Stamp - A rubber stamp with an assigned vendor number that is issued to each new WIC vendor.
Vendor Training Sign-In Sheet- Form #3756 titled Sign-In Sheet. Form is used for store owners/managers to sign when attending the annual vendor training.
Vendors, Review Form- Form #3774 titled Vendor Review Form is used when the local agencies are performing a monitoring visit at a WIC vendor site. It is also used when performing an inspection of a store that has applied to be a WIC vendor.
VOC Card - A certification card from a WIC clinic verifYing that the named person is a valid WIC participant entitling that individual to transfer certification to a new clinic.
VOC - Verification of certification confirming that all requirements for WIC participation have been satisfied.
Voided Vouchers -Both computer generated and manual vouchers may be voided for a variety of reasons. There are three different categories ofvoids: Voided Computer Generated Vouchers, Voided but issued manual vouchers, and Voided but Unissued Manual Vouchers.
Voucher Security- WIC vouchers are negotiable items which are presented to the bank as a check for cash reimbursement. Therefore all vouchers must be securely protected as checks or cash in order to help prevent voucher theft, and deter program fraud.
Voucher Number --The serial numbers of the vouchers produced for a participant.
Weight- Total weight in pounds and ounces of a participant.
Weight, Prior to Delivery- Indicates the woman's final weight immediately prior to delivery
WIC Type - Classifies WIC participants i.e., P=Pregnant Woman (Prenatal), N=Non-breastfeeding postpartum woman, B=Breastfeeding postpartum woman, !=Infant, and C=Child
WIC ID Number - Uniquely identifies the participant. It consist of 3 data elements. A 9 digit family identification number, a 1 digit check digit, and a 1 digit participant code. All members of a family should be assigned the same family identification number to facilitate voucher distribution.
"And Justice For All Poster" -Poster which must be displayed in a conspicuous location in each WIC Clinic site indicating the WIC non-discriminatory clause.

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