GA H~oo. P'8' Sl \NC:, /9q7 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 Nl\.1;i Pf.!!f~~.~~1t~i~~~=~~~i~'1}i{i)!)~~~!H Q.. iW:IP Pf()~~4Jtr~ .m@tti#Q~9~.gy. cI< D >-. 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 : ~=@l~i~i~il~s[~#.~4.~~g.g~y -....N..ati.o-n.a..J....N....o..t.e..r..R..,.....,....~..:-.istrat..i.:o.:.-n..A...e:.t.. 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 ! po~!fi~!i!I~~ :!r~g~@P.tm~~~im.~eymf~f!Ii~~~i! ~'i~!l:iii&~~ ~-?~1ii>.P9t!it~ --Seatch;Warran.rs .t. .rt:pb~'~~ s............Y.s..t..e..m.....i.n...d...i.c..*-...t..o.. t..R..:.e...p. o....r..t 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 VendotMatetia.Is ::.:.:;;:;>.;._.....~. ~....:: .;... :~:-:-:-.: . ' .. " . M!ii!9ffiiig PPJ.i>!~ai,ts~.ffiY.~~!iga~~ :Vefidorsan.ctions gg#),Pl~iH!J~L{;\g~ty;~gqq~ :ttmm~tl~I:t4?i~4~!:Hs~H'g!! 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 H_.,_..o...m....e.l.e..s..s.'n .e..s.s..,.M_.....i."~-..a..n.c. x"~7.a...n..t...r..H..~...i".s...a..s,..t,.,e. ..,i..S..i.,.,m.,.a. .t.i. .O,i.n G. Nutrition Education (NE) Section includes: Purpose, Definition, Goals of Nutrition Education State Agency Nutrition Staff and Responsibilities Local Agency Staff and Responsibilities ,>.,,_,:.,.P....a...n...i..c..i.P...a...n...r.,.,N.,_.,.,u,..t..,f..,i,t,.i..,a..,.n,i,,,,,.E,..a.u,;.:,,.c.,.,a,,,.,t..,i..."o""i'"i' R~s~l'~~~~~f~i.!:~.~i~gjm.~wB~!!B!~ :ns\i!rl!~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 Sectifity oCissuance>Matefi~ ....... ........ . . .. ...... .:. .. :-:.. :; ~ ::::.<.-:..... :..... ,R_ ,.e_,_d.,,e..m...P,t.i.o,..:.r.tof,W,,.,_,I,_C,_ ,V,,,,,,,o,,,_i.i_c._ ,.h,_.,e,_ts., Replacement ofVouchers ,<:A<.\u....t..o. .m....:a,t.,,e._,.a.sP .e..e.i.a.t/:'-.M,.-...a.. n_,_._u,,., a...t;:.,.,,,o,,_u..,e,,,.l,,.i:.e....t..sc.....:~,r,,,,s,,,,t,,:e,:m: ! ?:\!tt9m~t~'' o M....x.. ofMissm~Nouclier':iWO@kGardS ..... ...,.o.,......_...g>>>>>:-:-:o:->:>.>>>0:;>::::;:0:-o0:;:<::::::;:;:;o;..-o-::;.0.:.o.::.:.':,,--:-... :. $!~~-~gel1.~Y :Ji+q~~:~!~~~y if~~!f!~tg~!!P~R9! :.1:l~~ii~l~i~it.!~l;~g.~e~ :;~~~~i~i#~~t~t.~~~~~i.im1'~~~~::effi~&~~~~ . 'liltrod.Uction ;;}?g!i~~~~ . :r~~~~~~&i!l~l3?~f.3!a~~ :)5iB?B:~P.\:;2t~tm~t~29' g~P2~~P!!iti~~ . ;::g~q~~B:~q~~!~! 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 ~:, !BI~fi1gm~.~8~~~iiS.l :-'Ii1:\S :;.::;:::::Iti180Ii:;mEiiii:tw=iiliMJB%%fii1iit&iidili~lillii:ti:f:::ifffgi:IJ.l\0]1ili 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 RI:r!P '}\'g~b:::tft !.~E!J~~m.~\~1 G.]4,1,0 qi:?g ~!.!s~;~P:I':P!~J,~~~'fffi~~1~:o:I: =::;m:r::_T'I:m;;:m;::::::::::::::::lill:::::::::::~:m::::;:I: ;;;:.r.:msr::;:;r:::':,::,:n;,:,::::::r:rf,;,:,_;;_;:;,:,,:,r&I!7R ~1:7~2: ~!~t~!~s!;{g!Hijl!:~~m.~tEIk, Hmir1TT:m;~;:;;m::e::r:H:I:1;:,;.;;:J:;:;:.;:;:;,;_;:; 'il]:iii:::;:rm:I;J,l::@f,,...111:i,::[E1Iei1 cTt?~ mgmRgi~\l12x!tlti2m!~tffi~Iw;T:r;:::::i:;:;:;:mi:i:r:*ti::;:,mi;;;;rm::s;:;;:,mm.'}.Ii~~:@H,iiii1:'.:m::,:,,;:::;;,;,,,::;:~::!:~ 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, CT -I 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 CT-2 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. CT-3 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. CT-4 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. CT- 5 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 CT-6 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: CT-7 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 CT- 8 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: CT-9 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 CT -11 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~ CT-14 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 CT -15 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. CT -16 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 CT -17 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. CT-18 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. CT -19 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 CT-20 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). CT-21 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 CT-22 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; CT-24 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). CT-25 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.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-;;~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!-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<~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 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 .... .:;~;[.Jf;:m;t:::'o. .... . c;r::'.R04 F~ fi!M~mltt%2~1i~S~<;Y:!~~:;.;g:::;ws1r:m:r<:;:nu:: _;_TT:i .... . v?r;Rt: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 . .::::;>.. ~i:l~l.~~i~~=~~r.~~i,ti~l~~~~~~~~~l=lf4~i;:~~~~ qt!~~1~:I9~iiM:n~t;2~PM~~~::=::-:,13!P~l?!~lf~ .P.P:1P.J~~!ll~~~~g:;~!l!i!ri~.:.!?m.i !?!i~Jg~;p!f:g:~~!!~s!!~~!lli:'=;,:~f?.:~~W:!S!~m~:m!~~t~9.-~:::p~.tX.~~~ttt.:;4~P~~~~t~~ !!i~t~f~: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. R0-6 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 R0-7 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~ R0-8 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. R0-10 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/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~:'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~!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) R0-18 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 rw~ :vi ~!!~ ;~IX~ :::::::;..;..:.< :xf !1~l)QP!"'iq~~9-iYJfit9.~#~@9.. . .r. . . . >YIQ,ffii!P9f~~g;}8>,i!g~'#P:~it>TT '?T .: Ret.roactiVe:Benefits ana'Reffil15UfSement.::. ...:-:... .:. :-:.:-:.:.. ... ' ... ....:< >.. ..,.;.;.:.:::: .;..::>:-'~.:. ... ..:>>.-: .<<<'. r~.L\D':i?t w-.;.av.. ....""7:.:- . .-~'x::::::. .._,.~---......................... . .. . ._.. .~:: ::AD::s.:s "T')il)-;:4-0 %XJ;, '7~+4() ~!= XHH ':.)...:::-::::: Attachments: ..:i\1)-ttJ . i:f\I)42 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 ~it~, .mii!EffiY!P.?tmm~l.ln!:~~1t~,~a~Jt!cwi::t=::::;::::::y;::::mm:::'Im::m:;:.:;;;:;;;;]rum;;r~::r,g ~Eli!:~. - M!;~!R!~t[~e~~.~$!Iffi~s!ffi.l~f:!~t~~!fl.!tl~:;B-~i$it;ii:~::r:;;::fi:r~:~E{rm;:r:mm~;~ t:~~--~f2:t~J~~!~S::g~~1!s@il1:1Iil~:!i1:iEKM.f T:.f:Ii:1K:1::::,;;::li!fTI:ii:Hil@m!llilm:::iii:[;=;::m;::r:::T~i~~ ~~I~~:e#~e]ti2Hi~Rf.l:::;,::::li8: I;;m::m.;:;:::;=g(:;.m1t::I:I:::1;:::~:11=1::':::::::I:::iii.::=:=ii:r;w::,:I::~;i::=:t:l:m:m:=;:r:::r::m;:::::;.:~~ ' 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 AD-I 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. AD-2 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. AD-3 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 AD-4 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: AD-5 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 AD-6 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 AD-7 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 AD-8 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. AD-9 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. AD-10 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) AD-11 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. AD-12 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: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 AD-15 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). AD-16 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 AD-17 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 AD-18 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. AD -19 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. AD-24 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:cI~ 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~ iriformati().ri: L J' 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?.mWti~iP.j~: ~~: ~peffencigj ti#~e~ .gf:9~~fti'~~ ~~!~l9Pi4~A~ AD-37 GA WIC PROCEDURES MANUAL FY '97 Ptoceames:Fot:Responaiii~:?FoASuopoena v .w,Oo;<,,,.'' * * AD-38 GA WIC PROCEDURES MANUAL FY '97 ()f:-:t,ll.~.::::}Y.Ig :t.~~P:.t?~t':ruJx1t.Perqnen~.~~~1~s.a.ffi~ ~*$~ffi.~i. :tl1 ::Y!1~?2i;~ocaJ ~~J'i~xJ~t ~~~~ ~9~~1:.~pjlg'.#.;~t~p~pggt;~~t#!!~ffiptJ~ -- 1. ~il:~w~ 'pl.f9fi*atiof;1:Jff()r.m~H-9':=@~~:::.r~r~~w~4 ti'P~~:J?y::m~::f:5ftmi lW4!~4 ~P~~'it1to tli~ i':U.l?li:t~cot4) Iftheifi~tiontgq~}itlie~illif>C&~a~:aerueq:oy~tJ.i~s?~.}Ve re...c. o;tnm. ..e. r.i;d:.t..h. at.1..e>~t.at..:cO.o..ti.f..i..S. el:a.:;c..t.ing.,..o....i..ibeh...a...l..f..b'f;'fu>e'J'>S::>t'a:::t::e.:.:..o...i.. l()~ ag~p~yr~ffi!~~~:Ql,pf~~~)J!ti~~.to !41~~,~~?!~:.of th~;;~I~~.~:1!i~.~~ppg~~~$.mf6t!#~!iO~;~g;tJ.!~t.!~~f~~ ~.,.;m ;~s!JC>s~. ~~&s~::t~t.l9ffiP.!~;:::ID. Afi~~~Y{tP~t~:~~::~~~9t.9~!::JY:l:!Bt~t.t:t::!t?~~.}g~S!!~ ~~~g@'4~g,?tft{Eg~t~'l~W:AP.!!~@~:.tli.~~~2m1P:~!!.~~!:9f , ~p~~9.!4~P.w5":!t~tli!Y~~:R~:~2!iiP~U~q;!Sf!&~P'R~~ cbfitP AD-39 GA WIC PROCEDURES MANUAL FY '97 * * :-::::-:-:.::::-::.::-:-:;.:::-:-:; AD-40 GA WIC PROCEDURES MANUAL FY '97 &t~:it.W~t!YI~t~J:[q~:~'-f::tJi~t~!~P119:~e@~~-~R99fPm~mt:m~~~~8:t1! ~.W:rftt~l}~cmptt.i(~i~1~SRm~11t@~t:?) ~!4.PJ!.it!!~4~~. ~~ fq!!~M@g; ~: ~~:P2~~!1?.!~i:!~~H~.S).f.gt::!Pe:r~t~fsli:A.P~P~!Qffi~t,t~p~ b~ R!iffil~!i@s~P~P?P.:~~;ll~ 't:l9!i~~f~$;py ~s::~4.::g;t~.;ffiti:f:YI:~2Q) ct~x~s~9.n:;J?.!#@I,~e~<5,Wl;t~gilf~it.~!!~9ffi2~!i~i~~~~i 4. :r~e.l"f<>I1..?~~ip#ti<>tt:g~t~!T~chilisa1~~~st@~r:cs.~~:;~~1N9 :~sil!~r::~i?9Xf.Tm:9B~:qr ~f1.9y~~m!YW~"f1:2 ~kcW:t@~~~ !!i!~~pg9ffig~1f'<>~t~!.~.~!fi.iwproUP.g 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~ees'ilt correct the deficiencies \VithinJ5 Wniohitorlng~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.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~tiIJ~~.;~P,4 ...... < : 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, 3ilt 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~:-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 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 Scov 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 CSSalter 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>lS ot WIC Program fOOds. on all categoqeney: 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 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. prefeet \lerldo< ~signed in 111e pe10w 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 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 a1J;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-Ciliceeed 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 ProgQt3tn 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 POUCher 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~~. IlL BOTH PARnES AGREE AND COVENANT AS FOLLOWS: A. That no conllid of inleo 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 Proggr-.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--------- Sc: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. ~ (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 Jurisef 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 reimbut~ 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 lalwneor 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 $aln ol CWt Registers "' - - Social S.C..Oy- Nola!y Pubfic Signature and Seal Date Nola!y Pubfic's Commission Expires PURPOSE: This Agreement is tor the purpose ol providing a mechanism for the dislribtution of certain rested formula to efogible participants and the redemption of negotiable food instruments lor the pUrchase of said formula items. The Vendor is retained solely lor the pUrpose set for1h herein and shaH not be considered as an employee or agent o1 the Department. THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT .oooRESS Form 3782 (Rev. 796) Routing: White State WIC Office, Yellow Local Agency, Pink Vendor VN -43 GA WIC PROCEDURES MANUAL FY '97 Attachment VN-6 cont'd PHARMACY AGREEMENT WIC VENDOR NUMBER Page 2of 3 THE PHARMACY VENDOR HEREBY AGREES AND COVENANTS AS FOLLOWS: A Upon notifocation from the Local ~- to supply. within a time period agreed upon by the Pharmacy and the Local Agency. the necessary supply of any one of the "Special Infant Formulas". -_ a That all prices will be clearly marked either on the food item or prominently displayed. C. To accept WIC vouchers for payment of the purchase of only eligible WIC formulas. In addition. the vendor must accept all valid WIC vouchers. 0. To accept no WIC vouchers as payment on past or Pfesent credit account(s). E. To accept no WIC vouchers from participants presented after thirty (30) days from the issuance date or prior to issue date shown on the IIOUCher. F. To accept only vouchers which contain a Geopped SliEA NO. ~9459203 ~ THEK "Vol$ 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"rson(s) in lin -~ ~ I ~ ~ 0 .gr:: <" ~ ;:: ..E c < : u(..). :l ~ ... ..~- "" -'- ,, 0 0 ... .; ~ z 0 il=~~ :::li fS"f ... ~ ...tiS :r:: '!.-tO w . ~Cil . !f ~- c- ... -~~~...... oz w ::EC:: C'C~ ~~ .. --ctl Ul ..0.... Ul . 0 ~ = ~ f .. ~oil "0 .~ .... : ~ ,.1.~...:.-:.- .,...Ott) :r:::r:: _,z co I:I::E. t:: z~ e~, 1>1114- ;... ~~ .~ .... a:Z ;:,0 c:el.. >o:.:I.E, u 0 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 i w .-..........). I>!""' ~ ~ ""'::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.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,: 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 marlTot'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;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 FP- 1 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 FP -2 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. FP- 3 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. FP -4 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. ' FP- 5 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. FP -11 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. FP -13 REVISED 09/96 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. FP -16 REVISED 09/96 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. FP- 17 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. FP- 18 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. FP -19 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. FP- 21 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 FP- 23 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 FP -24 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 REVISED 09/96 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~~~?~a~!P,s~gP!~r~,t.~~~~~.~~~~:!Ql)~ ~~b-19.~$ @4 It#.~Y:~.;l!~~l!iP.,,fq't:.~e ~~@1~!1t~:f!~'!l()PY.l~!i!i_~~t.t$.9J#t~~,:P.2n !!~9:!~9#~ :~ef:y~~e~; l'M~_ptQ.@.~ttt. f~gi.!!~t!2f~ r~iiiif~l!lat .1-~ngWtq ##9J:LP.2!~fiti~ !IILI!Iii1~11~11l~~~== 'f:A~_,J1!'9.gf~:_9a.!~,gq!!~~~J~2~J?.~.\i:wqr-y;g:@:~Et~lti.P.a~~9~:!!~flm9~J49~~,~te~ ~p~ifq!~~~9;m:~ss~~wg~50,~~~~-:M,I:t.i!~lci!.l?.?I>ui~Y9~!:18:' ~g::ste~t~I~S?A~. g~fi!i:~~*-P'~~~~~9P.P!~P:Sfg':~. \g~9PP~(P!l~.~~!l~:f!!tl.i;:ts>iri~~iiiiifi~~~~7!!!!!i::!~Ji:!!r~~ ~j)ec~.~-~~~~~#s~a*c:J!~K~li~~lf!~~e~.~-~-e~:;!~:~-~~~~:i\Jid.,paryi.~ip~te.il(W!Qlf.~!!~J! s~ryices)..pe~~a!!~t2m!gl'_*P.tf~~!Y~fK~~;J9gt~tS.'-!tO~~~~~~;~ativ~-~~~~-!9!1 p;~~~~ngl~~:~v~~~gm4ft!~9~~;w.:~!f!g~!!~;r~~i.4mg.!ri~P:!l!n~ns~ll;~;P.!f~!~~ ~P~~4fi~*i!!'.i.~#~~; :.%A~~~"P~t9.BS~~Y9tt!~$11!2.!m!ae ifi~'~pecifis.g~~J?!,~!11 . I~~~P.~n =p()c*t;~W:l~m~s;~tr~~i9!.~;fqf~~~~.ae:9~~~bi.ficytq~J?~~t~ t()t~s:pqp:Ul~t~pp? A. Definition antSTocuses.on workers7nMe Pro~ ,. u..n...a.. ti ca.,.lJ:lY:?.,W' . .I.C:.....".s. de:0l.i..i.J..i.t'''io..l.. f. of'f. fi'i~.W.:c.ec... ..''. "farm..... ."- ..:''';<=><.:,, recO'@ize~ .9~~fL~~f!9W~W P2PP~~q~ ?~9gn~. a~ffii~{~its. A~99!!1!i empl6yni:erit.t~f~r$ !;\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~~-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!illili.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$8Q~:it~t~Y.~~)Y:pri,()t.tg.!a~ PU..b..li.c...h_. _@._._ ..ri_gs.__(___s__.~_..e._.A..tt.a.c.l)-.i..l..i....nt OR..../7. )__. and W..IC Pr:q.g"rar.i.l.. .r~-gula.l.i.o.n.s.: ......g.u..idelli.ie,s,,ar.e..r.n..t\.C..l...a.v.a.i.l.a.b.l.e:;t(i..;.f..].:.i..~-.1'l..l.[.jl.i.c. up,..o..n...~.e..g.U....~..s.t.;. This inclfides.tlie Federal Regulations,. the State Pian;.me;.Procedures'Manual arid:the Irtcome Gilidelines:Whelithe WICProg:tam Cd,ordinatots give~terviey.rs to:locaLtn.edi~ <>ti~etS,tJ.i~ ~!~~11t ~! P~9.!P~t!p~in..)Y:J:Q il~ siiJ:ti~itRfV~tX()nef.ig~n 'o/;4et--~dli2WJli~ OR-3 GA WIC PROCEDURES MANUAL FY'97 VI. OUTREACH DURING A WAITING LIST When local agencies reach their maximum caseload and a waiting list is instituted, outreach activities should be concentrated on the highest risk population. VII. PROGRAM COSTS Only costs of promotional efforts designed to encourage and increase participation in the WIC Program are allowable. Outreach efforts should be consistent with the health oriented nature of the WIC Program. Outreach expenditures are not allowable for meeting breastfeeding expenditure requirements. VIII. LOGO In FFY'94, a new logo was developed by the State WIC Office. The logo represents a mother and her children (see Attachment OR-6). OU!FRE'ACH/COORDINATION . ......... ... h~>'..''':::~, _.~,__,,,,, -. A. Outreach li r!~~9!?!~~8!!?.-gs 2; Stickers 3:: smi6afis ,-;;:,. :..;..'.>:>>>>: .:.<>. OR-4 GA WIC PROCEDURES MANUAL FY'97 TheY:: Cij:$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*~Pif~~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$'.and qtg@i~tio~)vffi.hshotild b~ contc1dteciregarding.the. ott!~~sQ.;referl'a!.~t:Ic<)()fg~i~!!P49t''\Y!P~~rYicesi~(';!ti~~; a}cof1Q1(4[ug .aouse ;9~~~mg:;snteti famiJ.Y:.ti?l~S.P #i~ttn~~.'.-.: :.:-:-:" . .,::' ' . . : ......... _.,._,_. .:...... . . . ; ..-.---:::-:-.< .-:-:-. _.. .:-.:-:.. ;:._._._ ... ... ..... -...... - . .... ; . . ~--. . ....... - .. -. OR-5 GA WIC PROCEDURES MANUAL FY'97 ~:1:~'' OR-6 GA WIC PROCEDURES MANUAL FY'97 ist() !nJ.prove ~eryice d}tyery ~d acce~~Jo seryices for potential p[:utiCip@ts by integrating/ctciiliating 'the '}~pplicatioll/eligibility. process; thereby elihifuatifig oigr~~tly:f~~~9f&~ilieclupli~atiort bfservices. . ... d. Astan.on-goj.rlg effort; ilieei1lglfiy~Stig~1~4~ .W... .I..C.-..i..s..1...i..e..s..r~......e...a..t..o P:..r..o..V..,.,i..d..e.:,.i:.,f.ot:cth.e......r..i..u....t..r...i..t..i...o.....rialca.r..e......<...>...fJ? arti...t..iP.a.n...ts. some Ho. we....v. er>.....:......... ~;==~tlEJSi~:ei~~~~ WIG soutesqf.tfettals-fqt.loca1 Ptpgrifuis~ asw(!llas~ loca} ~d st:ateinter-ag~t~y Progr~s.. Refefnils az-e ~se11t~alfor tl1~ coordination and the maximizati94 ()fsery!ss~ and tesoifrc~s~ It is.~ o!l':g()iri.g.~ffort;fof 1ocag)YICPro~lO'i:tlah1'Wn refelj~ iilfonriat!onf9i:~t!f locat~on/ A)'ef~rta.I ~[i)'.p~Jth:Ir!al()fit1fo@al> @sdepends]lporrthe re.asoil for~ referral~ Otb:ei"ifood 'i\gsistafice"pfogral)1$>~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:<.. : 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 ~} ~~~~~E9r~~~~A.91~!t9P:DFTJ:\jiEi728.: EG\!~~T ZT? ,:z.z:. : J.:I.:;_m :=:z-:ff!Ea! g: ~~'R~9:P:~!!~'~1~~:g~:.::!Is;;;:TIE:Siii'.:.'7:JTIJ;:-:TEt'::E:f.'7E'?~t;l ._,p'g:gBfg Page 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. FD-9 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: FD-10 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 FD-11 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. FD-13 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 FD-14 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~ ~,~!t!fi~fi!~!!;&f!:!!~lY!~~,I~!~l:~1!!!~~it\C!gt:1'~~:.g!!!ll~~3~ii!lj~:'~~g~9.~t ~..2~PJ~.!!!;:~,~r~!~~i'.!~g.!~l~f~!!~:~!P:~!~~~ ' 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, FD-17 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. FD-18 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. FD-19 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/ FD-20 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 FD-22 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 FD-23 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 FD-25 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. ~m,;i!s~8:::~l?I~~m~,~1.:Y~f~te~~ge~.s!Ie4m~Pf2!S'.P.Pit%H~ fl?l~~~m.~~!9!i:8P:ifs!!~~':W.#t1!..g~?t~um~At~g~ ~~patficipanf~petti,Q!.'~~9ts~ \Yli:~I,;t:~1P~S!!l~!!~!L@.!ffi@.l~~~:~J??~mattJ!if~9s~#~!!~~~ lost) ~9l~a~ pf~4~~tt65'~q, !h~:!:f:!fi~.pq!f~t~~ !:9i.'\i,!~~,~~mP.2t,;~!s;*!?.~m~t~~#.~~Rr~Jlias~m~il~i::92I!~:'!fi:~ar~.:~ ~~~@~~liJ?i~~~}.P.Y:~~tg~~}~t:.~'J?~~~"~~~t~fl~w4R~ !5!~9.:gar.!9 cliftici '.'.-.-;.;._:_,::....:.-:-:-: w-h~ii i~S.1!~g ~pi~s~tn~~fYf'~qh~ts, .~~fo.9.4 ra,c~~~:~~~t 9Iegs!~!~] 7Pffi.tsP.l~~~~tW?'\.Yi.*~n~m~~ District!UrliflClinic ,">:::-:-:::::;:; .,o,',":,,",,,V,:.,,,,','o"":"."":".\ . Cilft~~t,pa,!~ . B~gi!t.riit1g)f~p~ef t;f9Jll~~:P:f~gej E....i;.i.c;..:.l.l..i.r.!;tV....o...u...c...h...e..t..N;.:t..r...i.J.:te..*.. Qt~~.hfio/.i9t:M9H~l.!~~M.~~e :e~sfi'8F.#~~mfitm~1?~~ FD-33 GA WIC PROCEDURES MANUAL FY '97 * ~ ~!!!~::!-q~5.:::toi~tf;:9B~~.&&:~r;~g19ili!~~s~ llfl~~i~i:ril~i1l~~~l.tl11l~i11i!!1f~r~1c2:~~~~~~-P.~~r: t~~io5i;rti~?t~li~1flf~i:i2.!~~:x?H,s~~;:;~!P:n:l~~9nm.m! a~ Di~!ticf!PiiiY~!Wfq 15; Cil.ffentDate ~ :=~~lt~cli!t\...,~ e; Q~@lltit4f'Y':9.1!2li~~~~~~l!R~~f 2: MA.Qa~il tch6reitcroamc~tl,etre~d!:PU!o.S~.t/,S~~toll!ejnliD~e~s)tjtc~f~e~d-t~V~iolildcotoVf~o~u~u~~li:e~i~f~RXeI'~o~In~:~to-?~l~lti~e 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 Go.rttdtctor~ .-.:.......-.::;.-:..-:-:--:.:.;.;. 4~ ~fiY:\1::':!i%Y~;m~9}Y!~stW.~~t:;yt~ ~P Q:9n~c:@F::t~~iyed ~e vo~8~~ ~PP.~~g;_Wi1fi~l!~~ ~!1:@t:ey),!~fh~ yjjcJ1~ry;~~)*}1aye c~Iitaiii~E~ ~g9f}?:f.:~t,2Etg~~~g_;~psQ.~~pt!)f:iRY. t!i .P~ : ~~<)~o~~i>Y. eri!ite ~~1-&f fi~i~~~~~~i~l:f~ai~i.~~=~~'-~~~~~~~~~~z~t~~~~l~! ~9ITRt:::!!l.:Yfq~,:yo~~!~!.<~J':~!im.~S1i~w- tn~m!l!;~;:~!9.t:W:~C>It:ipin.Wim~-~~ AIJp;.:..;.>...; .;:.;.:=:::.:::>..;~ ~,:;:~.;., :;.;.:-~~;.. . FD-39 GA WIC PROCEDURES MANUAL FY '97 fJ@JuldfivA ,Q1Jii:if!t~fieiJI!:~deiiJf!tflClU...""t.~ Ol' 'P~C:UJ..X: {~} I ~= c::u::: ncr= ~J::tll: DJ..~ c: J ~ -~ -02/l(/12-----~-~---C-1-/-0-C-/f2-'-- lSS COl (21 ' ( l lS' C02 ~2~ ( ' J J -CISJH70 CSl.Cnl ~QfU.!.l) OSJH12 CSlH1J .C l c l ~ ~ - C l l/ l (/J 2 ' 02/-12. / !2 ' Jtl~ Mel / / OSJ,(7( CSJ((7S CISJ((1( CSJH17 .C Cll./ll/12 lS' 002{ 071 l 2 l . .O.S.J.H.7.C ~ CSJH1S CSJHCO ~ c 3 '' OSJHU .C 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 'WComposite 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. QI-2 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-'<.:-:---.'. 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~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 ....;._,.,_.,,.,./ ' ~-~- .;.'.. 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!!~@: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